Completing the Passages Program Application

At the bottom of this application, you may choose to either submit the application online, or you may print it and mail it to:

The Community School
PO Box 555
Camden, Maine 04843

IMPORTANT NOTE: PLEASE FOLLOW UP WITH A PHONE CALL TO VALERIE AT 236-3000 TO CONFIRM THAT YOUR APPLICATION WAS RECEIVED.

Passages Program Application

About You

Your Name:

Email Address:

Phone:

Best Time to call:

Social Security Number:

Birthdate:

Your Current Address

Street:

City:

State:

Zip:

Directions to your Home

Your Permanent Address

Street:

City:

State:

Zip:

Other Contact Information

If you move, who is most likely to know how to reach you?

What is that person's phone number?

Your Parents

Your Parents' Names:

Parent's Phone:

Is it okay to call your parents? Yes No

Children's Information

Are you pregnant? Yes No

If so, what is your due date?

Childrens name(s) and birthdate(s)

Are you currently in a relationship with the birthfather? Yes No

What is his name?

Where does he live?

School

Name of school you last attended:

What credits did you earn?

Who is a contact at the school?

Work

Are currently employed? Yes No

If yes, where?

Some Questions We Would Like to Ask

How did you hear about Passages?

Why are you interested in the passages Program now?

If you are working or involved with any other community agencies (TANF/ASPIRE, TEEN PARENT, EARLY START, WIC, MEDICAID, ETC), please list them here:

What is the one thing you've always wanted to do and are determined to do in your lifetime?

When are good days/times for the director to schedule a home visit?