Student Application

BCST Student Application

This application is for the Basic Computer Skills Training Program
Name*

First NameLast Name
What is your gender?*

FemaleMaleTransgender FemaleTransgender MaleGender Variant/Non-ConformingPrefer Not to AnswerOther
Address*
Street Address
Street Address Line 2
City*
City
State*
State
Zip Code*
Zip Code
What is your current country of residence?*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you hear about The Ladder Alliance?*

Emergency Contact
Emergency Contact Name:*
Emergency Contact Relationship:*
Emergency Contact Phone Number:*
Please enter a valid phone number.

Ladder Alliance Mission
The mission of The Ladder Alliance is to serve, in particular, women of domestic violence and those that are at risk. Since many of the agencies we work with do not necessarily serve this population, we are asking you to share with us whether you are currently involved in or have ever been involved in either a physically or mentally abusive relationship. (This information is kept confidential)*
Photography Release
There are times when we publish photographs of our students, for instance in an agency newsletter. We know there are those prospective students that do not want their photo published. May we use your photography?*

CONFIDENTIALITY STATEMENT

The undersigned agrees to keep confidential and to never disclose any "Confidential Information" obtained while acting as a volunteer, employee, independent contractor, or student, on behalf of The Ladder Alliance, Inc., even if the undersigned is no longer acting in such capacity, unless required to do so by an applicable law. Confidential Information shall mean any personal information about any student enrolled in classes provided by The Ladder Alliance, Inc. including, but not limited, to, the name, address, and telephone number of any student and the fact that any individual is a student of The Ladder Alliance, Inc.

RELEASE OF LIABILITY

The undersigned on behalf of himself/herself, and as guardian of any minor children, shall release, indemnify, and defend, and hold harmless The Ladder Alliance, Inc. and the owner(s) of the facility where any classes are held (the "Host"), as well as the employees, officers, directors, contractors, and agents of each of The Ladder Alliance and the Host (collectively, the "Actor") from and against all losses, liabilities, claims, or demands whatsoever (including, without limitation, costs and expenses in connection therewith), arising out of any personal injury or death, or out of any damage to or loss or destruction of property, in any manner based upon occasioned by, or attributable or occurring at damage the Host facility or during the transportation to or from the Host facility, if such transportation is provided by an Actor.

The Ladder Alliance does not discriminate against employees, applicants, volunteers, or clients on the basis of race, color, religion, creed, gender, nation origin, disability, marital or veteran status, or any other legally protected state.
Please sign if you agree to these terms.*

Clear
Confidentiality Pledge

I pledge that everything I hear in the classroom will be held in the strictest confidence, to protect others and myself as we work through the challenges and triumphs facing us.

I also understand that only through honesty and courage can change happen, and in this understanding, I pledge opennes and thoughtfulness to the process, along with a willingness to share with others both what is working for me, and what is not.

Finally, I understand that I will get out of this program what I put into it, and I agree to devote the time and energy, as well as thought, needed to improve myself in conjunction with what I learn through this program in the classroom.
Signature*

Clear
Should be Empty:

BCST Student Application

Emergency Contact

Other Information

Other Information cont.

Ladder Alliance Mission

Photography Release