Apply Now – Mississippi Youth ChalleNGe Academy

Dear Applicant

This is the welcome letter included in the official application packet.

I have read and understand this letter.

Search Policy

Please read the Academy's Search Policy in full.

I have read and understand the Search Policy.

Student Application

Applicant's Information

Social Security Number *

Is applicant a U.S. Citizen? *

Yes

No

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

M

F

Ethnicity *

Tribal Affiliation

Is this person Hispanic?

Does the applicant have an IEP (Individualized Education Program)?

Waiting to upload IEPs may result in your candidate's accommodations not being entered into the system in time for testing. Please ensure all IEPs are uploaded as soon as possible so the Testing Manager has adequate time to review and arrange the appropriate accommodations for each candidate.

Physical Appearance

Height

Weight

Hair Color

Eye Color

Clothing Sizes

Shirt Size *

Pants Size *

Shoe Size *

Hat Size *

Married?

Yes

No

# of Children

Who will keep your child/children?

Home Phone

Cell Phone

Other Phone

Email *

search Search Address

Mailing Address *

City

County

State *

MS

Zip Code

Parent/Guardian Information (to include DHS) - Legal Guardian(s) only

Relationship *

Name *

Home Phone

Work Phone

Mother Cell Phone

Mother's Email

Father Cell Phone

Father's Email

At least one phone number above (Home, Work, or Cell) * is required.

Mailing Address *

City *

County

State *

Zip *

Parental Acknowledgment & Consent

I the legal parent/guardian, am aware that the applicant will be facing many physical and mental challenges on a daily basis. These challenges are an integral part of the MS ChalleNGe Academy. I therefore agree and contract to support the efforts of the MS ChalleNGe Academy by supporting my applicant in his or her efforts to succeed. I am committed, to the maximum extent possible, to ensure my child remains in the MS ChalleNGe Academy until completion of the twenty-two-week residential phase and one year Post Residential Phase.

As parent or legal guardian, I hereby grant my permission for the physical screening evaluation and I further understand this exam does not prevent injury or sudden death during the applicant's participation.

I willingly and knowingly assume all liability for any and all bodily injury or property damage incurred by the participant. No fraternization or relationships beyond platonic are allowed for the duration of the program.

We the parent(s)/Guardian do consent to his/her participation in the Mississippi National Guard Youth ChalleNGe Academy, conducted at Camp Shelby, Mississippi. I/We authorize the participant to visit with the Mentor during the residential portion, and give permission for staff to discuss behavior issues with mentors upon successfully passing the required criminal background check.

I/we further agree that, if necessary, due to medical, disciplinary, or other reasons, the Director or Deputy may elect to return him/her to their home of record address by commercial or national carrier, for which I/we may be responsible for payment.

I/we consent to the applicant being photographed and/or videotaped while in residence, and to have such photographs and/or video posted on the official Academy website for official, non-commercial purposes only. I/we consent to the applicant being transported as a passenger in certain National Guard and/or air vehicles.

I/we understand I/we are responsible for the applicant's medical care and any incurred medical cost, and DO HEREBY consent in advance to whatever emergency, X-Ray, anesthesia, diagnostic procedure, medical and/or surgical treatment is considered necessary. Further consent is granted for psychological/educational assessments, evaluations and questionnaires/interviews. I/We consent to the program nurse as well as unlicensed cadre/staff to administer both prescription and OTC medications.

Eligible applicants must meet: 16-18 years of age at entry, no secondary school diploma, U.S. citizen or legal resident, unemployed/under-employed, not currently on parole/probation for other than juvenile status offenses, free from illegal drugs/substances, possess Medical/Medicaid Insurance, physically and mentally capable to participate with reasonable accommodation.

As parent/legal guardian, I have read this entire application and all its attachments. I approve of his/her participation, free of any compulsion. I am signing this Application and Release, releasing the Academy, all contracted agents, employees and volunteers from any and all liability arising out of participation.

Parent or Guardian Name *

Date

Signature *

This signature will be reused for the Insurance, Financial Responsibility and Security/Emergency sections ahead - you'll confirm using it on each.

Insurance & Patient Registration Form

Patient Information auto-filled from Step 3

Cadet's Name

Date of Birth

Sex

Cadet SSN

Address

City

State

Home Phone

Insurance Information

Insurance Type

Insurance Company

ID #

Group #

Subscriber Name

Relationship to Student

Subscriber Birth Date

Subscriber SSN

Policy Expiration Date

Copay Info

Primary Care Physician

Insurance Company Contact (from insurance card, if available)

Insurance Company Address

Address Line 2

City

State

Zip

Insurance Company Phone

Insurance Company Fax

Employer (of the insurance subscriber)

Employer Name

Employer Phone

Employer Address

City

State

Zip

Person Responsible for Bill After Insurance Pays

Name *

Social Security #

Date of Birth

Phone # *

Zip *

Address *

City *

State *

Please also provide a copy of the front and back of the medical card in the Documents step.

Signature required

This section requires the Parent/Guardian signature captured in Step 4.

Acknowledgement of Financial Responsibility

Medical Cost Waiver

Signature required

This section requires the Parent/Guardian signature captured in Step 4.

Medical History Form

Applicant: -

Has the applicant had any of the following injuries?

Yes	No	Condition	When		Yes	No	Condition	When
		Head Injury					Heart Murmur
		Shoulder L/R					Seizures
		Elbow					Kidney Disease
		Hip					Irregular Pulse
		Knees L/R					Single Testicle
		Chronic Shin Splints					Heart Disease
		Foot L/R					Liver Disease
		Pinched Nerve					Hernia
		Neck Injury/Stinger					High Blood Pressure
		Arm/Wrist/Hand L/R					Dizzy/fainting
		Back					Organ Loss
		Thigh L/R					Asthma
		Lower Leg L/R					Knocked out
		Ankle L/R					Diabetes
		Severe Muscle Strain					Tuberculosis
		Chest					Overnight in Hospital
		Are you pregnant?					Mononucleosis/Enlarged Spleen

List any previous Surgeries (Type and Dates)

Allergies

Current Medications

If the applicant is prescribed medication for conditions such as asthma, heart, depression or other mental health issues, a Medical Clearance form must be completed by the physician (next step).

Medical Clearance required?

Medical Clearance required

No Medical Clearance required

Medical Clearance

Based on your answer in the previous step, no Medical Clearance is required. You may continue.

Security and Emergency Information

Applicant's Information auto-filled from Step 3

Name

Age

Date of Birth

Social Security Number

Race

Sex

Mailing Address

Height

Weight

Hair Color

Eye Color

Tattoo/Scar Description

How did you learn about the Youth Challenge Academy?

Parent/Legal Guardian Information auto-filled from Step 3

Name of Parent/Legal Guardian

Relationship to Cadet

Mailing Address

Cell/Home Phone

Work Phone

Other Contact Information and Authorized Pick-up *

Cadet information can only be given to legal guardian. List any person you grant permission to pick up the applicant. At least one contact (name and relationship) is required.

Signature required

This section requires the Parent/Guardian signature captured in Step 4.

Please Attach Copies

These documents are an important part of the application and must be submitted with it.

Birth Certificate

Social Security Card

Proof of Insurance (Front)

Proof of Insurance (Back)

Immunization Record

info

By submitting this form, you confirm the information provided is accurate to the best of your knowledge. This is an initial application and does not guarantee enrollment.

Mississippi Youth ChalleNGe Academy

Dear Applicant

Search Policy

Student Application

Physical Appearance

Clothing Sizes

Parent/Guardian Information (to include DHS) - Legal Guardian(s) only

Second Legal Guardian

Parental Acknowledgment & Consent

Insurance & Patient Registration Form

Patient Information auto-filled from Step 3

Insurance Information

Person Responsible for Bill After Insurance Pays

Acknowledgement of Financial Responsibility

Medical History Form

Allergies

Current Medications

Medical Clearance

Security and Emergency Information

Applicant's Information auto-filled from Step 3

Parent/Legal Guardian Information auto-filled from Step 3

Other Contact Information and Authorized Pick-up *

Please Attach Copies

Application Submitted!