P.r.E.P Cohort 5
Class Registration Form
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
SSN
Optional
Format: 000-00-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the address on your government-Issued Photo ID match your current address?
*
Yes
No
Housing
*
Please Select
Rent
Own
Temporary Quarters
Homeless
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Are you a PCSI Client?
*
Yes
No
Gender
*
Male
Female
I Choose Not To Identify
Race
*
Black or African American
White
Native Hawaiian or Pacific Islander
Asian
Native American or Alaska Native
Two or More Races
I Choose Not to Self Identify Race
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
How Many People Live in your Household?
*
Are you a Veteran?
*
Yes
No
Do you have a criminal record?
*
Yes
No
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Domestic Partner
What is your Highest Level of Education?
*
9-12 Non-Graduate
GED
High School Diploma
Some College
College Degree
Graduate/Post Secondary Education
Other
Work Status
*
Not Employed
Employed Part-time
Employed Full-time
Retired
Self-Employed
Health Insurance Provider (ex: None,Medicaid, Medicare, UPMC, Allegheny Health Network, etc....
*
Do you need transportation assistance to attend classes?
*
Yes
No
How did you hear about this program?
*
Proof of ID
*
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of
Proof of Residency (Utility/Phone Bills and a piece of mail with your address on it)
*
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of
Proof of Income (a copy of your Paystubs, SSI Income Letter, Unemployment Compensation Letter, Pension Letter...
*
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Choose a file
Cancel
of
Submit
Should be Empty: