Civicorps Corpsmember Academy Application Form With Cover Letter Page 3
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8Office use only:
Office use only routing:
Start Date: ________________
Transcript attached
CIVICORPS
Immunization record attached
Recruiter
CORPSMEMBER ACADEMY
Work Permit (if applicable)
Entered into CMT ______
Dean of Students
Application
Start Date________________
Corpsmember File
101 Myrtle Street
Oakland, CA 94607
(510) 992-7800
APPLICANT INFORMATION:
SS# _______________________________________
Applicant’s Name
_______________
First
Last
Address
Street Address
Apt. #
City
State
Zip Code
Male / Female
Home Phone
Cell Phone
Date of Birth
____________________________
Marital Status (Single, Married, etc)
EMERGENCY CONTACT INFORMATION:
1
Parent/Guardian #1 (and relationship—for example: mother, grandfather, etc.)
Home/Cell Phone
Work Phone
2
Parent/Guardian #2 (and relationship—for example: father, foster parent, etc.)
Home/Cell Phone
Work Phone
3
Family Doctor/Local Medical Center
Address
Phone
Is this applicant able to participate in all physical education activities? Yes
No
If no, explain:
Is this applicant on medication? Yes
No
If yes, please specify :
Does this applicant have any special health conditions
?
Yes
No
(for example: asthma, seizures, hearing impaired, etc.)
If yes, please explain:
PREVIOUS SCHOOLING INFORMATION:
How many high school credits has this applicant completed? (If unknown, estimate)
Grade Level?
Has this applicant graduated from High School?
GED or Proficiency Exam?
______________
Previous High School(s) Attended (most recent first):
1
Name of High School
City
Last Date Attended
2
Name of High School (if applicable or if previous school was adult school)
City
Last Date Attended
1. Has this applicant ever been in a Special Education Program?
Yes
No
2. Was this applicant in a Special Education Program at the last school attended?
Yes
No
3. Does this applicant have an active IEP (Individualized Education Plan)?
Yes
No
4. Has this applicant passed any portion of the California High School Exit Exam (CAHSEE)?
Yes____ No____
If Yes, Which part has been passed (you must provide documentation): ___________________________________
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