Goodwill Industries of East Texas GoodTech Academy Participant Intake Form

Goodwill Industries of East Texas GoodTech Academy Participant Intake Form
This form has moved to another location
We have changed forms. You can click here to fill out to the new GoodTech Academy Interest form. If you have any issues, please contact goodtechacademy@goodwilletx.com
Participant Demographic Information
Today's Date*

MonthDayYear
Date
Name First and Last*
Birth Date*

MonthDayYear
Date
Primary Language:*
Gender*

MaleFemaleOther
Race*

African AmericanNative AmericanCaucasianAsianHispanicNon-HispanicBi-RacialOther
Address*
Street Address
City*
City
State*
State
Zip Code*
Zip Code
County*
Home Phone
Cell Phone
Disability or Barrier to Employment*
This includes documented disabilities, barriers to employment such as criminal background, at-risk youth, lack of high school education/GED, older worker (55+), and/or other disadvantages. *If you have no disabilities then enter none.
Email*
example@example.com
Education Level
The last completed or ongoing
Veteran:*

YesNo
Any Family Members Veteran?*

YesNo
Children under age of 18 living at home*

YesNo
Annual Household Income
Household Size #
Do you have Health Insurance

YesNo
Currently Homeless*

YesNo
Ever Experienced Homelessness*

YesNo
How long ago where you homeless Years Years Months Months
Employment Status*

EmployedUnemployedRetired
Place of Employment
Wage per hour at place of employment
Job Seeker*

YesNo
How were you referred to us?
Selecting Courses

What courses would you like to take?
Beginner Courses

Basic Computer LiteracyEmailInternetMicrosoft Office ProductsCompTIA IT FundamentalsGoogle FacebookGoogle UX-User Interface
Intermediate Courses

Google IT Support Professional CertificateGoogle IT Automation with PythonGoogle Data AnalyticsGoogle Project Manager
Advanced Courses

CompTIA A+CompTIA Network+CompTIA Security+CompTIA CySA+
Class Times

Day ClassNight Class
Any Comments
Signature*

Clear
Authorization For Release of Information

For a background check
First and Last Name:*
Date Of Birth:*
Last 4 of you Social Security #:*
DRIVER'S LICENSE # /STATE:
ADDRESS 1:
CITY:
State:
Zip Code:
ADDRESS 2:
City:
State:
Zip Code:
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Conviction History Form (CHF)
Have you ever been convicted of a crime (ANY crime, Misdemeanor and/or Felony)?*

YesNo
If Yes, Please explain here:
List Offenses, Current Status and Date
If Yes, Please explain here:
List Offenses, Current Status and Date
If Yes, Please explain here:
List Offenses, Current Status and Date
If Yes, Please explain here:
List Offenses, Current Status and Date
*In connection with my application for employment, I understand that an investigative report will be requested by Goodwill industries that will include information (at minimum)as to my criminal records sex offender status, SSN authenticity, driver's license authenticity, addess history and work references. I understand that as directed by policy and consistent with the job described, additional information from public and private sources about my motor vehicle driving records, civil court records, education, credit and credentials may be reviewed, I hereby authorize, without reservation, any law enforcement agency, institution , information services bureau, school, employer, or reference contacted by Goodwill Ind. or it's agent to furnish the information described above. I hereby release Goodwill Ind. and their agent and all persons, agencies and entities providing information and reports about me from any and all liabilities arising out of the request for or release of the above mentioned information or reports.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Disclosure Authorization Form
Today's Date*

MonthDayYear
(Authorization expires one year from this date)
In connection with your application for employment, Goodwill Industries of East Texas obtains consumer/investigative reports about applicants/candidates as part of the process of considering eligility for employment with Goodwill Industries. In the informationfrom the report(s) is used in making and adverse decision regarding your eligibility for employment, we will notify you with a written description of your legal rights.

By signing below, I hereby authorize Goodwill Industries of East Texas to obtain a consumer/investigative report about me in order to be considered for employment with their company.
In connection with your application for employment, Goodwill Industries of East Texas obtains consumer/investigative reports about applicants/candidates as part of the process of considering eligility for employment with Goodwill Industries. In the informationfrom the report(s) is used in making and adverse decision regarding your eligibility for employment, we will notify you with a written description of your legal rights.

By signing below, I hereby authorize Goodwill Industries of East Texas to obtain a consumer/investigative report about me in order to be considered for employment with their company.
In connection with your application for employment, Goodwill Industries of East Texas obtains consumer/investigative reports about applicants/candidates as part of the process of considering eligility for employment with Goodwill Industries. In the informationfrom the report(s) is used in making and adverse decision regarding your eligibility for employment, we will notify you with a written description of your legal rights.

By signing below, I hereby authorize Goodwill Industries of East Texas to obtain a consumer/investigative report about me in order to be considered for employment with their company.
In connection with your application for employment, Goodwill Industries of East Texas obtains consumer/investigative reports about applicants/candidates as part of the process of considering eligility for employment with Goodwill Industries. In the informationfrom the report(s) is used in making and adverse decision regarding your eligibility for employment, we will notify you with a written description of your legal rights.

By signing below, I hereby authorize Goodwill Industries of East Texas to obtain a consumer/investigative report about me in order to be considered for employment with their company.
Name First and Last:*
(Last, First, Middle)
Suffix (Jr/Sr)
Prior Name(s) Used:
Social Security Number:*
Date of Birth*
Phone Number*
Current Address:
Yrs:
Months.
City:
County
State:
Zip:
Previous Address:
Yrs.
Months:
City:
County:
State:
Zip:
Email Address*
Driver's License/State ID#
State:
Expires:
If you do not have a Driver's or State ID, please provide us with another form of acceptable identification (i.e., Military ID, Passport).
Picture of your ID ( Your ID will be required ) through this form or in person

Browse Files
In order to complete your back ground check a picture of your acceptable Identification is needed you can upload it here. Cancelof
Signature:*

Clear
Date:*

MonthDayYear
Date
Goodwill Industries of East Texas, INC. Consent and Release form
Name:*
Name of minor child or person unable to consent on his or her own behalf
I, _____________________, being either of legal age to consent or the legal parent or guardian of _____________________, a minor child or person unable to consent on his or her own behalf, hereinafter the (“other featured individual”) hereby grant to Goodwill Industries of East Texas, Inc. the right and permission to use the following collectively referred to as “Tangible and Intangible Items” for any lawful, non-commercial purpose and in any and all media without payment or any other consideration:

• pictures
• negatives
• reproductions and copies of original pictures
• negatives or recordings of me/the other featured individual
• any recordings that may be made of my/the other featured individual’s voice or likeness
• any written words or stories supplied by me/the other featured individual or written about me/the other featured individual

In addition, I waive any right to inspect or approve the nished product wherein my likeness appears. I hereby acknowledge that Goodwill Industries of East Texas, Inc. may grant the same permissions as set forth in this Consent and Release Form to Goodwill Industries International, Inc. (“GII”) under the same terms and conditions. This Consent and Release Form shall remain in effect for a period of ve years, unless revoked. I understand that I may revoke this consent by submitting a written request to Goodwill of East Texas. I understand that, if I revoke this consent, my revocation will not have any effect on actions already taken by Goodwill Industries of East Texas, Inc. and/or GII in reliance on my consent.

By signing below, I certify that I have read and understand this Consent and Release Form, I have been given the opportunity to have my questions answered, and I have been informed that Goodwill Industries of East Texas, Inc. must give me a copy of this document once it is signed
Authorized Signature*

Clear
Date*

MonthDayYear
Date
Name First and Last*
Authorized By:*
GoodTech Academy Student Expectation Form
In order to provide the best learning environment for students, Goodwill has set the following expectations for students enrolled in GoodTech Academy courses.
Attendance
All students are expected to attend classes throughout the entirety of the course. However, when a student is absent from regularly scheduled class times, the student is expected to provide notice to the instructor in advance by telephone. All students are expected to arrive for classes on time. Student tardiness can be disruptive to the learning process. Students may be dismissed from the class by the instructor if more than two sick days non –consecutive and/or two non-excused absences occur. Students will be required to make up absences on the Friday of the week missed. Students arriving late four times will be counted as one unexcused day.
Behavior
All students are expected to communicate professionally and abide by standards of personal communication in all aspects of the GoodTech Academy programs. These standards include:
Exam Vouchers
Two exam vouchers will be provided to each student and assisted with scheduling for exam certication. Students not passing an exam will not be provided with an additional exam voucher.
Internship/Job Placement
Students that pass both the 220-1001 and 220-1002 are required to complete at least 80 hours in an approved internship program. Students are then required to be placed in a job position by Goodwill Industries of East Texas.

By signing this form, you are agreeing to all of the above student expectations.
Student Signature:*

Clear
Student Printed Name*
Date*

MonthDayYear
Date
Authorized by:*
Disclosure of Vaccination Status
Section 1 – Disclosure of Vaccination Status
[All employees, consumers and students must complete Sections 1 and 2]

Per Goodwill Industries of East Texas Vaccination and Testing Policy all employees, consumers and students are required to disclose and provide proof of their vaccination status. Please complete this section in order to provide your vaccination status. This information must be kept confidential consistent with privacy laws.
Check only one box in this section:*

I want to be vaccinated. I have not yet received a vaccine for COVID-19 and wish to get information about becoming vaccinated. I understand that I will need to update this form once my vaccination is complete, and until then I will be required to comply with the conditions for all employees, consumers and students who are not Fully Vaccinated. More information about vaccination is available online at Frequently Asked Questions about COVID-19 VaccinationI am in the process of being vaccinated. I have started the process of receiving a vaccine/vaccine series for COVID-19. Until two weeks after the final dose, I understand that I will be required to comply with the conditions for all employees, consumers and students who are not Fully Vaccinated and that I will need to update this form once my vaccination is complete.I am Fully Vaccinated. I have completed my COVID-19 vaccination process. I will submit proof of vaccination (COVID-19 vaccination card, or written confirmation from my medical provider) to the Human Resource Department.I decline to be vaccinated. I do not wish to be vaccinated. I understand that I will be required to comply with the conditions for all employees, consumers and students who are not Fully Vaccinated unless or until I am able to be fully vaccinated. Employees are considered out of compliance with the vaccination program if they fail to completely fill out, sign, and submit all applicable forms and documents.
The date when I expect to be fully vaccinated (2 weeks after the final dose) is:

MonthDayYear
Date
Section 2 – Signature and Attestation

I declare under penalty of perjury under the laws of the State of Texas that the statement(s)in Section 1 above are true and correct.
Signature:*

Clear
Date*

MonthDayYear
Date
Printed Name*

First NameLast Name
Location*
Should be Empty:

Goodwill Industries of East Texas GoodTech Academy Participant Intake Form

This form has moved to another location

We have changed forms. You can click here to fill out to the new GoodTech Academy Interest form. If you have any issues, please contact goodtechacademy@goodwilletx.com

Participant Demographic Information

Selecting Courses

Authorization For Release of Information

Conviction History Form (CHF)

Disclosure Authorization Form

Goodwill Industries of East Texas, INC. Consent and Release form

GoodTech Academy Student Expectation Form

Attendance

Behavior

Exam Vouchers

Internship/Job Placement

Disclosure of Vaccination Status