Name * First Name Last Name Course Selection * Please select which course you wish to apply for. Certified Nursing Assistant Phlebotomy HVAC Plumbing EMT Bookkeeping GED ESL OTHER Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone Number * (###) ### #### Date of Birth * XX/XX/XXXX MM DD YYYY Date of Application * MM DD YYYY Gender Male Female Other Race/Ethnicity * Asian/Pacific Islander Black/African American Hispanic/Latino Native American/Alaskan Native White/Caucasian Race/Ethnicity Not Listed Annual Student Income * Annual Individual Gross Salary (previous calendar year) $ Annual Household Annual Income * Annual Gross Salary for entire household (previous calendar year) $ Household size # of people in the home including yourself 1 2 3 4 5 6+ Highest Level of Education Completed * Less than High School Diploma/ GED equivalent High School Diploma/ GED equivalent Some College/No Degree Associates Degree Bachelors Degree Masters Degree or higher Primary Language Used * English Spanish Other Not Listed Would you be interested in the ESL program offered? Yes No Are you currently employed? * Yes No Are you currently employed in the field of program study you are applying for? * Yes No Not Applicable/Unemployed Check the geographic areas in which you are interested in for employment. * City of Smithville Bastrop County Fayette/Lee County Austin/Metro Area Other Metro Area Not Listed Other Rural Area Not Listed Are you in need of assistance in any of the following areas for sake of completing this program? * Transportation Child Care Language Barrier Technology Access Job Placement Other If you are in need of assistance, please explain below: How did you hear about this class? * Check all that apply. Smithville Workforce Website Community Action Website Workforce Solutions Website Social Media Friends/Family Flier/Radio Housing Authority San Marcos ISD Other Have you ever completed a career training class with Community Action? * (CNA, Medication Aide, Phlebotomy, etc.) Yes No Are you able to legally work in the United States? * Yes No Are you able to attend ALL training class days? * (Tuesday, Wednesday and Thursday 9-12PM) Yes No Other (Please explain below) Other: This class will require a significant amount of time (at lease 5 hours per week) completing homework assignments and quizzes. Will you be able to commit time to completing these assignments? * Yes No Maybe/Unsure Thank you for submitting your information! Please complete application on the next link.
