CAREER DEVELOPMENT PROGRAM APPLICATION FORM
PLEASE NOTE:
WE ARE NOT TAKING ANY MORE APPLICATIONS FOR THE MEDICAL ASSISTANT PROGRAM FOR THIS SPRING 2026 SEMESTER.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Which class are you interested in?
*
Customer Services & Sales
Warehouse & Forklift
Certified Medical Assistant
Which cohort would you like to join?
*
Fall 2026
Do you live in Dallas County?
*
Yes
No
Do you have a refugee, immigrant or asylee legal status?
*
Refugee
Immigrant
Asylum seeker
Are you legally able to work in the United States?
*
Yes
No
Are you able to speak English?
*
Yes
No
What is your proficiency level of English?
*
Beginner
Upper Beginner
Intermediate
Advanced
Are you able to read in English?
*
Yes
No
Are you able to write in English?
*
Yes
No
Do you possess a basic level of proficiency in Math? (adding, subtracting, multiplication and dividing numbers)? I am comfortable with using a calculator.
*
Yes, I have a basic level of Math
No, I do not know math
I am comfortable using a calculator
No, I do not know how to use a calculator
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Are you 18 years of age or older?
*
Yes
No
Do you have access to transportation to and from classes at Northwest Community Center or training at other sites in Dallas County?
*
Yes
No
Do you have a GED or High School Diploma?
*
Yes
No
Do you have a college/university degree or any other certifications? Please list.
*
Are you currently experiencing homelessness?
*
Yes
No
Do you have an open legal case that could result in jail time and interfere with your attendance at job training?
*
Yes
No
What is your current employment situation?
*
I work full time
I work part time
Self employed
I am not working
What are your career goals? Please share near-term goals and dreams for the future (a few years from now)
*
Do you have access to a personal computer and the internet at home?
*
Yes
No
Are you open to having a mentor to encourage and advise you?
*
Yes
No
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Next
If you have children, what are your plans for their care while you are training or at work?
*
Our program is designed to help you to work in a full-time job which pays a minimum of $20/hour. Are you willing and able to work full-time in your new job after completing our program?
*
Yes
No
What types of government assistance do you receive?
*
SSDI
SSI
TANF
CCAP
Unemployment
SNAP/Food Stamps
Medicaid
Section 8
None
Other
Do you consent to a drug screening and a background check? (Some career tracks require these before enrollment)?
*
Yes
No
I am willing to attend training 12-16 hours per week for up to 20 weeks, based on the career path being pursued.
*
Yes
No
I understand that eligibility for this program does not guarantee enrollment in any specific career track. Each career track has additional requirements. All options and limitations will be discussed in the enrollment process.
*
Yes, I understand
No, I do not understand
By completing this form, you agree to receive text messages from Northwest Community Center. Message and data rates may apply. Message frequency varies. Reply HELP for help and STOP to cancel.
*
Yes, I agree
No, I do not agree
Signature
*
NOTE: Filling out this form does not imply acceptance into the program. You will go through an interview process after filling out the application.
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