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Gateway Academy Screener

2. Gateway Academy Services Request

4. First Name*

5. Last Name*

7. Date of Birth
   Date of Birth

   please enter the mm/dd/yyyy for your date of birth.

8. Email address:

9. Telephone number

11. Address1

13. City

14. State

15. Zip

17. Are you currently a Norfolk resident? *

    1. Yes
    2. No

19. Are you currently receiving SNAP or Medicaid benefits?*

    1. Yes
    2. No

21. Are you currently receiving TANF benefits?*

    1. Yes
    2. No

23. Was your employment impacted by the COVID-19 pandemic?*

    1. Yes
    2. No

25. If you answered Yes, to the above question, please check one of the below on how you were impacted by COVID-19*

    Enter N/A if you answered No to being impacted by the COVID-19 pandemic.

    1. Laid Off
    2. Furloughed
    3. Reduction in hours/pay
    4. Terminated
    5. Other
    6. N/A
27. Have you ever been convicted of a misdemeanor or felony charge*

    1. Yes
    2. No

29. Are you between the age of 18-49 years old with no dependents on your SNAP case? Please answer N/A if you do not have SNAP benefits.

    1. Yes
    2. No
    3. N/A

31. Are you a youth or young adult (age 17-27) who is transitioning out of foster care?

    1. Yes
    2. No

33. Do you have a child support case with TANF debt owed?

    1. Yes
    2. No

35. Which training program are you interested in?

    1. Certified Nursing Assistant
    2. Commercial Drivers License - Class A
    3. CompTIA A+
    4. Construction & Facilities Technology
    5. Culinary Arts
    6. Pharmacy Technician
    7. Medical Billing & Coding

37. Additional comments

39. How did you hear about us?

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field