Program Interested In	Choose Program Community Health Worker Connections Pre-Apprentice Carpenty Pre-Apprentice Electrician Pre-Apprentice Heavy Equipment Operator Pre-Apprentice Painting Pre-Apprentice Plumbing Pre-Apprentice Sheet Metal Pre-Apprentice Welding PSEO Career Options Weatherization Technician Undecided
	First Name
	Last Name
	Email
	Street Address
	Apt/Suite
	City
	State	Choose State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	Zip Code
	Day Phone
	Evening Phone
	Cell Phone
	Gender	Choose One Female Male
	Ethnic Origin	Caucasian Hispanic African African-American Asian/Pacific Islander American Indian/Alaskan Native Somali Other:
	Citizenship	Choose One US Citizen Eligible Non-Citizen Non-Citizen
	Status (check ALL that apply)	US Veteran Displaced Homemaker Disabled Dislocated Worker Limited English Speaker Incarcerated Chemical Dependency Ex-offender * Other:
	* If Ex-offender, date of release
	Marital Status	Choose One Single Married Divorced/Widowed Seperated
	Family Status	Single Head of Household * Married, Spouse present with children Married, Spouse present NO children Non-custodial parent Living alone / friends Living with parents / relatives Other:
	* If Single Head of Household, # of dependents
	Income Source (monthly)	I have no source of income Employed
	MFIP cash $
	Food Stamps $
	Child Support $
	Alimony $
	SSI $
	Veterans Benefits $
	Unemployment $
	Other Income Source
	Other $
	Employment Status (at enrollment)	Choose One Full-Time Part-Time Unemployed
	Employer Name
	Hours per Week
	Wage per Hour
	Salary per Year $
	Check ALL potential barriers that may hinder your enrollment	Housing Child Care Drug/Substance Abuse Transportation Health Issues Pending Court Appearances Financial Stability Relationship Issues Clothing Other:
	How did you hear about us?
Terms and Conditions
Summit Academy OIC adheres to the principle that all persons regardless of race, color, creed, religion, national origin, sex, disability, sexual orientation, marital status or status with regard to public assistance have equal opportunity and access to admissions, employment, facilities and all programs and activities of the school. I understand that I must submit all materials required for admission to Summit Academy OIC PRIOR to admittance. I hereby certify that the information on this application is accurate and complete to the best of my knowledge. I understand that I must update data on this application if circumstances change the accuracy of the previously provided information. By checking the box below and submitting this application, I agree to abide by and be subject to Summit Academy's rules, regulations and disciplinary code.
	Signature	I Agree