MWA4LF Program Application

Program Application

Mike Williams Assist 4 Life
General Information
Student Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Gender *
Please indicate your ethnicity (Select one or more)*

American Indian or Alaskan NativeAsianBlack or African AmericanHispanic/LatinoWhiteI prefer not to answer.Other
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email (the email address you check)*
example@example.com
Phone Number*
Please enter a valid phone number.

Emergency Contact

In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person*

First NameLast Name
Emergency Phone Number *
Please enter a valid phone number.
Emergency Contact Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Commitment Form

Due to the objective training plan, if accepted, students will be required to visit active job sites and possibly be exposed to on job training. If accepted, a parent or guardian consent form must be filled out before orientation. The program outline is extensive and may even roll into the summer months. The student's commitment to attending all activities, except for approved absences, is paramount to the student.
I, First Name* Last Name* , understand the importance of attendance and the requirements stated above for the Mike Williams Assist 4 Life program. If accepted, I agree to uphold the expected level of commitment to succeed during my time in the program. It is signed Date* .
Student Signature*

Clear

Reminders

An Assist 4 Life Admin will interview students as part of the screening test. It is essential to complete all requirements before the program starts. Failure to do so will delay the students from joining Assist 4 Life. MEDICAL CLEARANCE. The program requires all students to have a yearly physical exam. For new students, medical clearance from their doctor of school doctor is required. PARENTAL CONSENT AND WAIVER OF LIABILITY. Due to on-site training, each student will be required to submit a consent and waiver of liability form signed by a parent or guardian. MEDIA RELEASE. Students are required to submit a media release form signed by a parent or guardian.
Date Signed *

MonthDayYear
Date
Student Signature *

Clear
Date

MonthDayYear
Date
https://www.signupgenius.com/go/10C0F49A4A72AA2FBC34-53688111-mike

Please copy and paste this link and select the best time for your quick interview. If non of these times work please email mewilliams@assist4life.org.
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Program Application