RHA LDI Profile & Participation Agreement
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Ethnicity
*
African-American
Native Hawaiian/Other Pacific Islander
Asian
American Indian/Alaska Native
White
Hispanic or Latino
Other
Are you currently employed?
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Yes
No
Housing Resident?
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Yes
No
Sponsored by Employer?
*
Yes
No
Emergency Contact: Name
*
First Name
Last Name
Emergency Contact: Phone Number
*
-
Area Code
Phone Number
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Highest Education Level
*
Please Select
Some High school
High school diploma/GED
Certificate
Some College
Associate Degree
Bachelor's Degree
Master Degree
Doctorate Degree
Computer Skills
*
I have an email address and communicate with email
I use Microsoft Word
I search the Internet
I use Facebook or other Social Media
I have no experience
Other
What is your dream job?
*
How did you hear about the LDI program?
*
Please Select
Internet
RHA Staff
Word of Mouth
LDI Instructor
Newspaper
Social Media
Other...
In what areas do you feel you need the most improvement?
*
Positive Attitude
Attendance
Responsibility
Professionalism
Problem-Solving
Communication
Team Work
Adaptability
Other
Why did you join the LDI program?
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What do you expect from the LDI program upon completion?
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Current LDI Class Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
While participating in LDI, I as a participant shall:
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Rows
Initials
Attend all scheduled class sessions, showing up before class starts and staying until class is excused (To graduate, only 1 day or 3 total instruction hours may be an excused absence meaning you called in your absence before class started).
Take the WorkKeys and Talent Assessments.
Have a positive attitude.
Respect the individual opinions, rights, safety and property of others.
Act professional - no obscene, discriminatory or percussive language.
Dress professional - no jeans, t-shirts or tennis shoes.
Be open to learning new skills and practicing the skills.
Set goals and complete action steps.
Participate in class discussion and activities, including work study.
Silence cell phones while class is in session.
Use provided technology solely for its intended use unless otherwise given permission.
Not possess or use weapons, alcoholic beverages, tobacco and/or illegal drugs.
Terms and Conditions:
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Rows
Agree
I am aware of the inherent risks and dangers associated with LDI. I agree to accept these risks and dangers. Further, I agree to release, hold harmless and indemnify the Rockford Housing Authority, its employees, agents and officers for any claims, losses, costs incurred in my failure to abide by the Participation requirements or arising out of my LDI Participation.
I hereby give my consent for a written statement, photograph, digital image, and/or video or audio recording to be obtained, produced and used for any LDI Program marketing purposes and in Rockford Housing Authority materials.
I am 17 years or older and by my signature below, I acknowledge receipt of this document and acknowledge that I have read and agree to abide by the guidelines in this document. I am aware that if I violate the agreement, at the Dean of Business's discretion, the Dean of Business may ask me to leave class or terminate my participation.
Electronic Signature
*
Submit
Should be Empty: