Please fill out this application to the best of your best ability. Please keep in mind that some of the questions may not apply to you. If you have any questions about this application, please contact us. Copy and paste this form to a Word Document and send by email, Fax or mail and we will contact you. Students must not currently be enrolled anywhere and need to know that they can not graduate from this program. This is a transitional program only. Students wishing to obtain high school credits must bring their work to the school district for determination of credits. Wendy Cohen is a Certified Colorado Teacher.
___________________________________________________________________________ Date: ______________
Last Name, First Name, Middle Initial
Date of Birth / / / Age:_______ Male_________ Female______
Home Address: _________________________________________________________________________________
Home Phone: _____________________________
Personal Email:________________________________________
Cell phone:___________________
Current Employer: _______________________________________________________________________________
Position: ____________________________________________ Time in Current Position______________________
Cell Phone: ______________________________________
Last School Attended ____________________ Last grade completed _____________
Parent/Guardian
First name _________________ Last Name ___________________ relationship to applicant __________________
Contact phone number __________________________ Best time to contact ___________________
On probation? _______ Probation officer’s name_____________________________ phone__________________
Special needs
Do you have any special needs? __________ Are you in the care of a mental health professional? _________
On medication______ physical needs ________under psychiatric care_________ Name of Psychiatrist______________
Language needs ______
Is English spoken in the home______ What is your primary language ________________________
Why are you applying to this program?
What strengths will you bring to this program?
What areas are you willing to improve while you are here?
What are your long range educational goals?
This year:
Next year:
Two years from now:
What are you willing to do to stay committed to this program? I am willing to
(Please bring in a copy of your most current transcripts)
REFERENCES
Personal or professional references (Please exclude relatives.)
1. Name: ____________________________________________________ Phone: __________________________
Address: _____________________________ City ______________________ State _______ ZIP _______________
2. Name: ____________________________________________________ Phone: __________________________
Address: _____________________________ City ______________________ State _______ ZIP _______________
EMERGENCY CONTACT INFORMATION
Primary Contact: Individual to be notified in case of emergency:
Name: ___________________________________________________ Relationship: ________________________
Address: _______________________________ Phone #1: _________________ Phone #2: ___________________
Secondary Contact: Individual to be notified in case of emergency:
Name: ___________________________________________________ Relationship: ________________________
Address: _______________________________ Phone #1: _________________ Phone #2: ___________________
Insurance Agency:_______________________________________ Doctor’s Name___________________________
THE ABOVE INFORMATION IS ACCURATE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE _____________________________________________________ DATE ________________________
YOUR SIGNATURE INDICATES YOUR APPROVAL FOR US TO CHECK YOUR REFERENCES. THE ORGANIZATION IS NOT OBLIGATED TO PROVIDE A PLACEMENT, NOR ARE YOU OBLIGATED TO ACCEPT THE POSITION OFFERED.
Please return this form to:
2 Hearts 4 Lacy
3600 Mitchell Drive Suite 50 B
Fort Collins, Co 80525
-or-
Twohearts4lacy@aol.com
-or-
fax to 303-200-8066
It is the student’s responsibility(not the parents) to call and set up an interview once the application is completed: 970-266-9652.
