Eligibility Application

This is the last step in our selection process. Please fill out this form accurately and honestly.

Student Information


Personal History

Parent Name / Financial Guarantor

Other Parent Name

Other Emergency Contact

Personal Medical Information

Medical Contact Information

Insurance Coverage Information

Medical Insurance Information

Dental Insurance Information





Please be as open and honest as possible. This is your chance to speak from the heart and express how you feel. You might want to talk about where you find yourself today, what personal choices may have contributed to your current situation and what you would like to change about it. What you talk about is entirely up to you. Please proof read your work and ensure grammar and punctuation is correct.