RHA WDI Profile & Participation Agreement
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male
Female
Ethnicity
*
White
African-American
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Hispanic or Latino
Other
Housing Resident?
*
Yes
No
Are you currently employed?
*
Yes
No
Sponsored by Employer?
*
Yes
No
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
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 WDI program?
*
Please Select
Internet
RHA Staff
Word of Mouth
WDI 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
ALL OF THE ABOVE
Other
Why did you join the WDI program?
*
What do you expect from the WDI program upon completion?
*
Current WDI Class Start Date
*
-
Month
-
Day
Year
Date Picker Icon
While participating in WDI, I as a participant shall:
*
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.).
Yes
No
Take the WorkKeys and Talent Assessments.
Yes
No
Have a positive attitude.
Yes
No
Respect the individual opinions, rights, safety and property of others.
Yes
No
Act professional - no obscene, discriminatory or percussive language.
Yes
No
Dress professional - no jeans, t-shirts or tennis shoes.
Yes
No
Be open to learning new skills and practicing the skills.
Yes
No
Set goals and complete action steps.
Yes
No
Participate in class discussion and activities, including work study.
Yes
No
Silence cell phones while class is in session.
Yes
No
Use provided technology solely for its intended use unless otherwise given permission.
Yes
No
Not possess or use weapons, alcoholic beverages, tobacco and/or illegal drugs.
Yes
No
Terms and Conditions:
*
Agree
I am aware of the inherent risks and dangers associated with WDI. 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 WDI 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 WDI 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
*
First Name
Last Name
Submit
Should be Empty: