EMPOWER Academy Application

Student Information for HS EMPOWER Academy

Please fill out all information completely.

Date of Application*

Answer required for "Date of Application"

If you answered, OTHER above, please tell us how you hear about SouthernTech's EmPower Academy.

Answer required for "If you answered, OTHER above, please tell us how you hear about SouthernTech's EmPower Academy."

Last High School Attended*

Answer required for "Last High School Attended"

Present Grade*

Answer required for "Present Grade"

First Name*

Answer required for "First Name"

Last Name*

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Email Address*

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Date of Birth*

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Age*

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Race/Ethnicity

Check All That Apply

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American Indian or Alaska Native

Black or African American

Hispanic

Caucasian

Asian

Pacific Islander

Other:

Are You a Single Parent?*

Answer required for "Are You a Single Parent?"

Yes

Street Address*

Answer required for "Street Address"

City*

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Zip/Postal*

Answer required for "Zip/Postal"

*Please make sure all phone numbers listed are current and if numbers change, see one of the secretaries in the main office.

*Student Cell Phone Number*

Number Required

Name of Parent/Legal Guardian

Answer required for "Name of Parent/Legal Guardian"

*Parent/Legal Guardian Cell Phone Number

Number Required

Parent/Guardian's Place of Employment

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*Work Phone Number

Number Required

Emergency Contact Information

Full Name*

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Relationship*

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*Phone Number*

Number Required

Personal Background Information

Education: Please select the highest grade completed*

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Why are you interested in attending SouthernTech and EMPOWER Academy?*

Answer required for "Why are you interested in attending SouthernTech and EMPOWER Academy?"

Will you need transportation to SouthernTech?*

Answer required for "Will you need transportation to SouthernTech?"

Yes

If no, how will you get to SouthernTech?

Answer required for "If no, how will you get to SouthernTech?"

Please explain your choice(s) above*

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If you dropped out of high school, when did you drop out and why? (Please explain)*

Answer required for "If you dropped out of high school, when did you drop out and why? (Please explain)"

Can you think of anything that could have encouraged you to stay in school? If yes, please explain.

Answer required for "Can you think of anything that could have encouraged you to stay in school? If yes, please explain."

Confidential Information

Are you currently expelled or suspended from any school for violation of school codes regarding fighting, weapons, drugs, or anything else?*

Answer required for "Are you currently expelled or suspended from any school for violation of school codes regarding fighting, weapons, drugs, or anything else?"

Yes

If you answered yes, please explain below. What is the date and length of time of your suspension or expulsion and what is the name of the school

Answer required for "If you answered yes, please explain below. What is the date and length of time of your suspension or expulsion and what is the name of the school"

Have you ever been a resident of a detention center, children's shelter, boy's home, jail, etc?*

Answer required for "Have you ever been a resident of a detention center, children's shelter, boy's home, jail, etc?"

Yes

If you answered yes, please explain below.

Answer required for "If you answered yes, please explain below."

Are you currently under the supervision of a probation or parole officer?*

Answer required for "Are you currently under the supervision of a probation or parole officer?"

Yes

If you answer yes, what is the name of the agency and person you report to?

Answer required for "If you answer yes, what is the name of the agency and person you report to?"

What is their phone number?

Number Required

Please fix the highlighted areas below before submitting.

EMPOWER Academy Application

Student Information for HS EMPOWER Academy

Emergency Contact Information

Personal Background Information

Confidential Information