Fresh Start Intake Form

If you see this don't fill out this input box.

Student Information

Name*

Residential Address*

Phone Number

Alternative Contact Number

Email Address*

M Number or Social Security Number*

Date of Birth*

Gender

Ethnicity/Race

Are you a new American Citizen or recent immigrant?

Yes

Housing Needs?

Prior Living Situation?

Current Profession

Educational Background

Do you have a High School Diploma or GED?

I have a High School Diploma

I have a GED

I have neither

Previous College

Did you ever attend college through a CIPP? If yes, what program?

What is your major

Eligibility Criteria & Requirements

Identify how you meet the eligibility requirements

Arrest History

Recent Felony conviction(s)

Time Served

Who were you referred by?

Correctional/Juvenile facility you were in

Year Released

Parole/Probation Officer

Parole/Probation Officer's Phone Number

List any Addiction/Rehab programs you've attended.

Other Criminal Charges

Violent Behavior

Mental/Physical Health

Military Service

If yes, do you have a DD214?

If yes, how were you discharged

If yes, do you receive services from the V.A.? What services?

Special needs. What kind of support do you need in the classroom?

Student Success

Are there any barriers/obstacles that may hinder your academic success at MVCC?

Do you have reliable transportation?

How did you hear about the Fresh START Program

Would you like to participate in the Fresh START mentoring program?

Please provide your Employability Profile from DOCCS if you have one.