Workforce Development Academy registration form

Workforce Development Academy for Youth
Participant Information
Participant Name*

First NameLast Name
Birth Date*

MonthDayYear
MaleFemale
African American/BlackCaucasian/WhiteHispanic/LatinoAmerican Indian/AlaskanPacific Islander/AsianOther
What High School did you attend?*
Highest grade completed*
High School DiplomaHigh School Equivalency (GED)IEP (Individualized Education Plan)Diploma/Disabled with certificate of completionDropped outOther
Are you a U.S. Citizen?
If not, are you authorized to work in the U.S.?
Are you homeless?
Are you a parent?
Are you an English Language Learner?
Have you ever been convicted of an offense (misdemeanor or felony)?
Are you low-income?
Are you or your family receiving any public assistance?
If yes, what type are you receiving (TANF, Food stamps/SNAP, SSDI, SSI, RCA, GA?
Do you have a disability?
Are you currently employed?
If no, how many weeks have you been out of work?
If yes, are you full time or part time?
What are some goals you have for yourself (educational/career/personal)?*
Short and long term goals (over the next 6 months to a year)
What are some of your strengths?*
What are some of your weaknesses?*
What has held you back from completing your goals?*
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Number*

Area CodePhone Number
Secondary Number

Area CodePhone Number
E-mail*
Social MediaNewsletterEmailFlyerWord of mouthOrganizational eventPublicationWebsiteOther
OUR EXPECTATIONS: Be on time to all appointments, be respectful, complete tasks as assigned, maintain regular contact with your case manager, agree to take all tests and assessments that will assist in your educational and career path and DO NOT QUIT ON YOURSELF!
I hereby give my consent to be contacted for further eligibility information. I understand a Case Manager will contact me to discuss my goals and current situation. It is my responsibility to maintain regular contact with my case manager and complete all the necessary workshops to achieve my goals. If I am not able to be contacted for a period of 90 days or more, I will be exited from the program.
Date*

MonthDayYear
Date
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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Workforce Development Academy for Youth