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Student Registration

Contact Information
Name
Date of Birth (mm/dd/yy)	/ /			Age
Phone
Message Number
Address
City		State		Zip

Emergency Contact Information
Contact Name
Relationship
Phone

Demographics
Race/Ethnicity	Asian African-American Caucasian/White Hispanic Other, please specify:
Living Status	With Parents Foster Parent Homeless Shelter Alone Friend(s) Relative(s) Girlfriend Other, please specify:
Education	Number of Years:
High School Graduate?	Yes N o	If yes, what year graduated?
GED?	Yes N o	If yes, what year completed?
College?	Yes N o	If yes, what year completed?
Legal Status	Emancipated , Date: Probation , Date: Parole , Date:

Please provide information for all that apply.
Probation/Parole Officer:		Tel:		Ext:
Mental Health Worker:		Tel:		Ext:
Social Worker:		Tel:		Ext:

Additional Information

Please tell us any information about you that will help us understand why you are interested in participating in New Life Construction Training Program.

Thank you for your interest in our program. We will respond to your registration form as quickly as possible. If you have any questions please contact Barbara Collazo at (661) 366 - 8003 or email barbara@newlifecenter.us.com