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Fast Forward Application Form

Your pathway back to school and a diploma

Applicant Information

Full Name:
Last First M.I.
Address:
Street Address Apt. #

City State Zip


Cell Phone: Home Phone:
E-mail:

Gender: Male Female Birth Date: Age:

Ethnicity: American Asian or Pacific African Hispanic White Other:


Indian/Alaskan Islander American
Native

Emergency Contact:
Name Relationship to you Phone
How did you hear about this program
program?

Parents’/Guardians’ Information
*Please complete if under 18. Write “same” if the information is the same; write “none
“none” if the info is unknown or unavailable.

Mother’s Name: Father’s Name:


Street Address: Street Address:
City/State/Zip: City/State/Zip:
Phone: Phone:
E-mail: E-mail:

Academic History
*Please list in order of last attended. Write “none” if the information is unknown or unavailable.
Name of High Schoolss Previously Attended Location (City/State) Years Attended

Why did you stop attending classes?


Please mark all that apply.
Disinterested in classes/ Attendance (Missed too Financial reasons (Had to Didn’t get along with
school many days to catch up) get a job) teachers/classmates
Curriculum/schoolwork To take care of a family Health issues Not motivated to work
was too hard member/child hard in school
Scheduling issues Suspended/expelled Family reasons Transportation issues

Other:

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Fast Forward Application Form
Your pathway back to school and a diploma

Placement Assessments
*For office use only. Applicant, please leave blank.
MAPs – Reading MAPs – Math Compass ACT MSP/HSPE

Informal Assessment Observations & Notes:

Photo Consent
*If under 18, please have parent/guardian sign consent.
Yes, I give permission for the Boys & Girls Club to use photographs of me/my child for promotional
purposes, and waive any claims I may have against the Boys & Girls Club for all thereof.
No, I do not give permission for the Boys & Girls Clubs to use photographs of me/my child.

Applicant’s Signature: Date:

Guardian’s Signature: Date:

Permission To Gather/Share Information


*If under 18, please have parent/guardian sign consent.

I hereby give permission for the Fast Forward Program to gather, share, and use my academic records,
including transcripts, assessment results, and other school records. In addition, I give permission for the
program to share any pertinent information regarding my involvement with the program to individuals,
government agencies, and/or other entities involved with my participation with the program (i.e.,
educational institutions, GED testing center, food stamps office, unemployment agency, etc.).

Applicant’s Signature: Date:

Guardian’s Signature: Date:

Please submit completed application in-person, via mail or e-mail to:


Boys & Girls Club
Attn: Fast Forward Program
801 N. 18th Ave.
Pasco, W A 99301
jen@kidexpert.org

If you have any questions, please call us at (509)416-0304.

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