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18
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1
Where did you hear about this opportunity?
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Baton Rouge North Economic Development District
Southern University
Baton Rouge Community College
Career & Technical Education Center
Social Media
Other
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Please Select
Baton Rouge North Economic Development District
Southern University
Baton Rouge Community College
Career & Technical Education Center
Social Media
Other
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2
Name
First Name
Last Name
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3
Email
example@example.com
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4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Phone Number
Please enter a valid phone number.
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6
Do you live in one of the following zip codes? (Check One)
70805
70807
70811
other
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7
Where do you currently live?
(Check one)
Baker
East Baton Rouge Parish
Port Allen
Other
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8
Highest Level of Education Completed
Please Select
Option1 Some High School
Option 2 High School Graduate
Option 3 GED
Option 4 Some College
Option 5 College Graduate
Option 6 Other
Please Select
Please Select
Option1 Some High School
Option 2 High School Graduate
Option 3 GED
Option 4 Some College
Option 5 College Graduate
Option 6 Other
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9
Employment Status
Please Select
Option 1 Unemployed
Option 2 Part-Time
Option 3 Full-Time
Option 4 Seeking New Opportunities
Please Select
Please Select
Option 1 Unemployed
Option 2 Part-Time
Option 3 Full-Time
Option 4 Seeking New Opportunities
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10
Are you currently enrolled in any job training or certification programs?
YES
NO
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11
Program Interest & Career Goals
Please Select
Option 1 ✅ Construction & Skilled Trades (NCCER, Electrical, Welding)
Option 2 ✅ Clean Energy (Solar, Wind, EV Charging)
Option 3✅ Engineering & Technology
Option 4 ✅ Business & Public Policy
Option 5 ✅ Healthcare & Allied Health
Option 6 ✅ Agriculture & Sustainability
Option 7 ✅ Other (Write-in option)
Option 8 Interest in furthering higher education via EMACE at Southern University.
Please Select
Please Select
Option 1 ✅ Construction & Skilled Trades (NCCER, Electrical, Welding)
Option 2 ✅ Clean Energy (Solar, Wind, EV Charging)
Option 3✅ Engineering & Technology
Option 4 ✅ Business & Public Policy
Option 5 ✅ Healthcare & Allied Health
Option 6 ✅ Agriculture & Sustainability
Option 7 ✅ Other (Write-in option)
Option 8 Interest in furthering higher education via EMACE at Southern University.
What career field are you most interested in? (Check One)
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12
Why are you interested in this program?
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13
What certifications or skills are you hoping to gain?
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14
Do you have any prior work experience in your field of interest?
(Yes/No – If Yes, describe briefly)
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15
Support Services
Wrap Around Services
Please Select
Option 1 ✅ Transportation Assistance
Option 2 ✅ Childcare Support
Option 3 ✅ Financial Assistance/Stipends
Option 4 ✅ Resume & Career Coaching
Option 5 ✅ Mentorship
Option 6 ✅ Other (Write-in option)
Please Select
Please Select
Option 1 ✅ Transportation Assistance
Option 2 ✅ Childcare Support
Option 3 ✅ Financial Assistance/Stipends
Option 4 ✅ Resume & Career Coaching
Option 5 ✅ Mentorship
Option 6 ✅ Other (Write-in option)
Do you need any support services to participate? (Check One)
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16
Are you interested in a internship or job placement opportunities?
YES
NO
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17
Availability
Full - Time
Part-Time
Evenings
Weekends
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18
Date
-
Date
Year
Month
Day
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