19-24 Opportunity R3 Pre-registration Survey

Name *First Name, Middle Initial, Last Name

Age *

Gender *

Date of Birth *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address *

Phone *

Which of the following best describes you?

U.S. CitizenRefugeePermanent residentOther

Which form of education certification do you have?

High School DiplomaGEDCollege DegreeOther

Last school attented

Are you currently enrolled in school? *YesNo

Are you currently working? *YesNo

Are you a resident of Shelby County? *YesNo

Which describes your current mode of transportation? *

I have a VEHICLE that I drive.I ride with others that have a VEHICLE.I ride the BUS frequently.I use ride share like UBER and LYFT.

Which form of identification do you have? *

Driver's LicenseState IDNone

Have you ever been charged with a crime? *YesNo

What career grabs your interest? *

What is your biggest worry right now *

Who is the most influential person in your life right now? *

How did you come to hear about this program *

Below are the 2024 dates for upcoming sessions. Choose your preference. *

Fall 2024 SessionWinter 2025 SessionSpring 2025 Session

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You will receive a call within 72 hours following your submission of this pre-registration survey. Please make sure that you have answered all questions honestly and accurately. If you are selected to move to the next round for registration, you will need to report in person to complete other registration documents and meet with a pathway specialist. Congratulations on completing the 1st step and good luck to you. Your dream opportunity is almost within reach.

Opportunity R3 Pre-registration Survey

T-Shirt Size

Which of the following best describes you?

Which form of education certification do you have?

Which describes your current mode of transportation? *

Which form of identification do you have? *

Below are the 2024 dates for upcoming sessions. Choose your preference. *