IMPACT! Program Application

Personal Information

First Name:*

Middle Name:

Last Name: *

Preferred Name: *

Street Address:*

City:*

Zip:*

Email*

Phone.:*

Text Number (if different):*

I authorize IMPACT!/BTC to text appointment reminders and other communications.

Preferred pronouns:*

Gender:*

Age:*

  16 17 18 19 20 21

Date of Birth*

Demographic Information

The following demographic questions are intended to assess student need and provide appropriate services. Your answers are kept confidential and will not have any bearing on admission to the IMPACT! program

Which race do you consider yourself?*

  White African American American Indian Alaska Native Native Hawaiian Other Pacific Islander Vietnamese Chinese Filipino Korean Japanese Other Asian Other Race

If other race, please specify:

Are you of Latino/Hispanic ethnicity? *

No, not Hispanic Mexican, Mexican American, Chicano Puerto Rican Cuban Other Latino/Hispanic

At home, what languages are spoken?*

Disability status:*

Do you have a physical or mental impairment which substantially limits one or more major life activities, such as seeing, hearing, speaking, walking, learning, working, etc.?

 Yes

 No

 Unsure

Additional Contacts

Parent/Guardian Names:*

Relationship to you?*

Address (include city):*

Phone:*

Emergency Contact Name:*

Relationship to you?*

Emergency Contact Phone:*

The following demographic questions are intended to assess student need and provide appropriate services. Your answers are kept confidential and will not have any bearing on admission to the IMPACT! program

Additional Information

Do you have a GED?*

 Yes

 No

Have you ever been suspended or expelled from school?*

 Yes

 No

If yes, please indicate which school and the circumstances

Which highschool did you last attend?*

  Homeschool Bellingham Highschool Blaine Highschool Ferndale Highschool Lynden Highschool Meridian Highschool Mt Baker Highschool Nooksack Highschool Options Highschool Sehome Highschool Squalicum Highschool Other

If other, please indicate which school

Do you have a probation officer?*

 Yes

 No

If yes, please name who

Please list charges (pending or adjudicated):

Do you have an active BECCA petition? *

 Yes

 No

Is anyone (court, parent, counselor) requiring you to attend school as a condition of participation in other programs? *

 Yes

 No

If yes, please indicate who and why

Have you ever had an individualized education plan (IEP) or been provided with additional resources at school to help you learn? *

 Yes

 No

If yes, please name your IEP teacher

Are you currently in stable housing? *

 Yes

 No

 Unsure

Describe your transportation to BTC: *

Education Goals

Beyond high school completion, what are you interested in? *

  A BTC Program Two year Transfer Degree Four year University Work Experience All Applicable None of the Above

If you are interested in a BTC program, which one? *

If None of the Above, let us know what you are interested in *

Student Essay

Please write 3-5 paragraphs explaining why you are interested in the IMPACT! program, and what your goals are for the 3-5 years after you complete your GED. Where do you see yourself academically (will you still be in school, if so for what?), job-wise, and personally?

What wasn't working with your previous school?

I certify that the information above and in my accompanying personal statement is true and correct to the best of my knowledge.

I have read this form carefully. I understand that an incomplete request may not be processed.

What happens next?

Click the "Submit" button below to submit the application.

Once the request is submitted, a confirmation will be sent to the email you entered above.

Please click the "Submit" button only once. this may take a few seconds to process