Healthcare Workforce Training Application

Personal Information
Application Date:                            Entry Status:  *                                                    * Required Fields
    Last Name:                     *   First Name:   *   MI:   * If no middle initial, please Enter #.
    Address:                          *     Apartment/Unit#:  
    City/State/Zip:                 *
    Primary Phone:                *                                          Alt Phone:  
    Email Address:                *                 
    Birth Date:                        Month:   * Day:  * Year:  * 6.  Age:  
    U.S. Citizen?:                   * Visa type: 
    Gender:                            *
    Ethnicity:                          *
    Race:                                *
    Selective Service Status: *       Selective Service Number:  
    Veteran Status:               *   If yes, Date(s) of Service:  
    Spouse of Veteran:         *
    Branch of Military:        
    TAA Recipient?:             *
Employment Status
    Currently Employed?:    * Underemployed: working part-time or working job not commensurate with skills and education.
    Monthly Income:            *
    Receiving Unemployment Insurance?: *
        Laid Off?:                       *
        TANF?:                          *
        Food Stamps?:               *
    High School Diploma/GED/HiSET:            *                                      Month:   *
    Highest Education Level:                             * High School Diploma or equivalent is required.
    Most Recently Attended College Name:      Month:    
    Other College Name:                                      Month:    
    Area of Study Interest:                                *
  Please Share With Us How You Learned About the Program:                  Other Source:   *
This workforce product was funded by a grant awarded by the U.S. Department of Labor’s Employment and Training Administration. The product was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The U.S. Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership.
Accommodations Statement
St. Louis Community College is committed to providing access and reasonable accommodations for individuals with disabilities. If you have accommodation needs, please contact the Access office at the campus where you are registering at least six weeks prior to the start of class to request accommodations. Event accommodation requests should be made with the event coordinator at least two working days prior to the event. Documentation of disability may be required.
Non-Discrimination Statement
St. Louis Community College is committed to non-discrimination and equal opportunities in its admissions, educational programs, activities and employment regardless of race, color, creed, religion, sex, sexual orientation, national origin, ancestry, age, disability, genetic information or status as a disabled or Vietnam-era veteran and shall take action necessary to ensure non-discrimination.
PRIVACY NOTICE In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Labor is authorized to collect information to implement the Trade Adjustment Assistance Community College and Career Training Program under 19 USC 2372 – 2372a. The purpose for collecting this information is to administer the program and evaluate participant progress. Providing this information, including a social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled.