JSCC AE Elevate Registration Form

Please complete all sections fully and accurately and return with your completed Eligibility and Affirmation for Employment Preparation or Career Pathways Services form (if applicable)

Name
Address
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Sex
Marital Status:
8.) Ethnic Group
Race
Veteran Status
If yes, please select your status from these options:
What is your high school/GED completion status?
Have you provided the program with your SSN? (If no, please inform your AE Instructor)
Do you have access to the email address provided? If no, please inform your AE Instructor

Eligibility and Affirmation for Employment Preparation or Career Pathways Services

Name
Address
Are you a parent of a child who lives with you and who is under age 18, or 18 and in secondary school?
Are you the parent of a child or children who are not living with you but who are under age 18 or age 18 and in high school? Yes
Do you provide care for any related children under age 18, or 18 and in secondary school, living with you?

If you answered no to A, B and C, you are not eligible for the Employment Preparation Services Program.

Do you receive Family Assistance benefits from the Department of Human Resources?
Do you receive Food Assistance benefits?
Do you or your children receive Medicaid benefits?
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

SPONSOR will not discriminate against apprenticeship applicants or apprentices based on race, color, religion, national 01igln, sex (including pregnancy and gender Identity), sexual orientation, genetic information, or because they are an individual with a disability or aperson40-years old or older. SPONSOR will take affirmative action to provide equal opportunity ln apprenticeship and will operate the apprenticeship program as required under Title 29 of the Code of Federal Regulations, part 30. Program Registration and Apprenticeship Agreement Office of Apprenticeship. U.S. Department of Labor Employment and Training Administration Voluntary Disability Disclosure 0MB No. 1205-0223 Expiration Date: 03/31/2023
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