ENROLL FORM

ENROLL FORM
Name

First NameMiddle InitialLast Name
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth
Gender/Sex
E-mail
Your Phone Number

Area CodePhone Number
Phone Number #2 (if applicable)

Area CodePhone Number
Social Security # (optional to complete in person)
Race
Ethnicity
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Telephone Number

Area CodePhone Number
Marital Status
Military Service?

YesNo
Current Household Income (Self)
# of People Living in Household
What are the CURRENT barriers keeping you from gaining or maintaining employment? (Check all that apply)

Criminal RecordSubstance Abuse IssuesLack of Work HistoryPregnant/Parenting YouthLack of Literacy SkillsLack of Driver’s LicenseMental IllnessDisabilityLack of Qualifications/ExperienceLack of ChildcareUnstable Housing SituationLack of TransportationLack of Computer SkillsLimited English ProficiencyLack of G.E.D./High School DiplomaChronic Health Issue(s)Medical/Health IssuesLack of ResumeDislocated Worker (Terminated or Laid Off)
Highest Grade Level completed
Are you currently employed?
If Yes, Where? How long?
How long have you been unemployed?
How many jobs have you had in the last 5 years?
(If employed) Employer
Wage
# Hours/Week
Benefits Received (No/Yes)
Are you currently receiving any of these public benefits? (PLEASE CHECK ALL THAT APPLY)

Medicaid or MedicareWIA AdultWICUnemployment BenefitsChild Care VoucherOtherSNAP (Food Stamps)Housing Assistance _TANF ChildcareTANF Transportation
Are you currently receiving services from any other community organization(s) i.e. Vocational Rehabilitation, Brighton Center
If yes, please list
How many children do you have, if any?
How many children live with you (please include ages)?
Do you have any physical or mental condition that may interfere with your ability to work?
If yes, please describe diagnosed/undiagnosed conditions. Include past conditions:
Have you ever been diagnosed with a physical or mental condition?
If yes, please describe condition & any medicines currently prescribed:
Do you have any criminal convictions?

If Yes, complete

	Describe Conviction(s)/Charge	Is this a FELONY/MISDEMEANOR?	Date(s)	County or Location	Are you on PROBATION/PAROLE (Yes/No)?
1
2
3

Please select your response below.

	Strongly Disagree	Disagree	Agree	Strongly Agree
I feel helpless to change my life.
I feel hopeful.
I know how to manage my life well.
I am ready to change.

Photo Release and Right to Privacy Agreement

By signing below, I consent to the use of my picture or image by the Life Learning Center for the purposes of illustration, advertising, video programming or publication either alone or in connection with photographs and or video tape of other persons or objects.

I release all employees of The Life Learning Center from any and all liability of every nature arising from such use.

With my signature I also acknowledge my understanding that the information requested from me will be used by the Life Learning Center to improve my employment opportunities and change journey. I understand that my personal information may be shared with other partners, providers and/or employers to enhance my opportunities for growth.
CANDIDATE DRUG FREE POLICY

Life Learning Center has a zero tolerance drug policy. We believe that active illegal drug use is a barrier to transformational change and sustainable employment.

In accordance with this policy, part of our get to know you process is to administer a drug test to all potential candidates. The following points are intended as a guideline for how the tests results will affect your eligibility to participate in our program. By signing this form you are acknowledging the terms of this policy.
- All candidates will be administered a drug test prior to a get to know you discussion with staff.
- Following the get to know you discussion, the results of your drug test will be shared with you.
- If the test is positive for any legally prescribed drugs the candidate will be given the opportunity to provide an active and valid prescription for the substance identified. The prescription must be provided prior to the start of the program they are enrolled in. If a prescription is not provided prior to the start of class the candidate will not be eligible to participate in Life Learning Center programs.
- If the test is positive for any illegal substance (i.e. Heroin, marijuana, etc.) The candidate will not be eligible to participate in Life Learning center programs.
- In the event that a candidate is determined to be ineligible because of positive drug test; they may reapply for consideration and submit another drug test after a minimum of thirty (30) days has passed since the prior test.
- Life Learning Center reserves the right to request additional drug tests while the candidate is enrolled in Life Learning Center programs to ensure candidate remains drug free.
My signature on this form grants the Life Learning Center permission to conduct a drug and alcohol screening at the Life Learning Centers’ discretion and expense and check with any or all local, state, or federal government, police, or penal authorities for past and pending arrest and conviction information.

With my signature below I acknowledge that I have read the above policy guidelines. (Please print copy and sign)

________________________________________________________________________________
Who Referred You? (i.e. Who told you about enrolling in our program?)
Should be Empty: