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DMVA - Keystone State ChalleNGe Academy Request Information Form

DMVA - Keystone State ChalleNGe Academy Request Information Form

Section 1: Youth’s Information

Please complete the Request Information form found below to find out more about the KSCA.

Submitting this Request for Information form does not mean you have officially applied or been accepted to the KSCA. The KSCA will start accepting applications in January 2022. After submitting this form one of our Regional Admissions Advisors will contact you within two business days to provide specific information about our program and the application requirements. Begin your application process as soon as you know you may be interested in attending. An application does not obligate you to attend or guarantee admission to the program.

We look forward to working with parents and applicants to make this process a smooth one.

Required fields are marked with an asterisk.(*)

First Name

**

Last Name

**

Address Line 1

**

Address Line 2

*

City

**

County

*

State

*

Zip Code

**

Youth must be a Pennsylvania resident. Youth must be 16-18 years-old on the first day class starts.

Birthdate

**

Gender

**

Section 2: Parent/Legal Guardian Information

Name

**

Relationship to Youth

**

Address Line 1 (If different than youth's)

*

Address Line 2

*

City

*

State

Zip Code

*

Phone Number (XXX-XX-XXXX)

*

Email

***

Preferred Contact Method

Phone

Email

Text

Mail

Best Time to Contact

**

Section 3: Additional Questions (To be completed by youth)

How did you find out about ChalleNGe?

*

Please Specify name from your previous response

**

Please state why you desire to be accepted to the ChalleNGe Program. (Our program is 100% voluntary.):

**

Have you ever been convicted of/facing criminal charges?

*

Have you ever been convicted of/facing criminal charges? NoHave you ever been convicted of/facing criminal charges? Yes

Are you at-risk of not completing high school or have dropped out?

*

At Risk or High School Dropout NoAt Risk or High School Dropout Yes

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