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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 Medical Assistant
    2. Certified Nursing Assistant
    3. Certified Professional Food Manager
    4. Commercial Drivers License - Class A
    5. CompTIA A+
    6. Medical Billing & Coding
    7. Pharmacy Technician
    8. Phlebotomy Technician
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