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Kankakee Community CollegeHighway Construction Careers Training Program

INITIAL REGISTRATION FORMPlease complete, save file as a PDF document and email as an attachment to jwillard@kcc.edu or print and mail to

John Willard, KCC Highway Construction Careers Training Program, 100 College Drive, Kankakee IL 60901.

Please fill in the blanks or the applicable boxes for each item below. Please print.

Personal Information Today’s date ____/____/____

PLEASE PRINT.

Name:LAST FIRST MIDDLE (FULL)

Street address: Apt. no.: PO Box:

City: State: ZIP code: County:

Home phone: ( ) - Work/alternate phone: ( ) - Birth date: ____/____/____

E-mail address (optional):

Gender: Male Female

Do you have a disability requiring special attention? Yes No If yes, please describe: ____________________________________________________

What language does your household usually speak at home? English Spanish Other _______________________

Ethnic background (choose one) Alaskan Native American Indian Asian Black/African-American Hispanic Latin-American Pacific Islander White/Caucasian Other _______________________

CONTACTS:

This section MUST be completed in order to gain entrance into the program. Please list two reliable contacts. These should be individuals that you have daily contact with are who can reach you if our office cannot. These individuals must have phone numbers.

Emergency contact:

Name: Relationship:LAST FIRST

Street address: Apt. no.:

City: State: ZIP code: County:

Phone: ( ) -

Message contact:

Name: Relationship:LAST FIRST

Street address: Apt. no.:

City: State: ZIP code: County:

Phone: ( ) -

How did you hear about this program?(check all that apply) Educational institution Housing program/shelter IETC/IDES Faith-based organization WIA Health/medical institution DHS/TANF LLCC website

Letter/call/presentation from staff LLCC brochure Media: Newspaper, radio, etc. Participant/friend in the program Social service agency Other _______________________

EDUCATION

What is your highest level of education? (diploma, degree, etc.)

Less than high school GED/high school Associate degree Bachelor’s degree Postgraduate work or degree Certificate/license

Are you presently in school or an educational program? Yes No If yes, name of school/program __________________________________________________________________________

EMPLOYMENT AND ECONOMIC SITUATION:

What is your current employment status? Full-time Part-Time Unemployed Seasonal

Indicate occupational field or job title: ____________________________________________________________________

What is your marital status? Single Divorced Married Widowed Separated

Sources of income: Salary Child Support SSI Unemployment Self Employment Social Security Food Stamps Pension T.A.N.F. Other Public Assistance Medicare/Medicaid

Additional information

Have you ever been convicted of a felony or misdemeanor? Yes NoIf yes, what was the conviction charge? _____________________________________________________________________ Date: ____/____/____

Make and model of your current vehicle: _________________________________________________________________

Insurance carrier: _______________________________________________________________________________________

Valid driver’s license number: ____________________________________________________________________________

NOTICE OF CERTIFICATION: I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud. I understand that this information will be kept confidential and will not be released to the public. I have been advised that this information will be entered into a computerized information system and may be shared with other authorized agencies for the purpose of administering programs of these agencies. I understand that I have the right to inspect this information and initiate appropriate corrections through the agency to which I am providing this information.

____________________________________________________________________ __________________________ SIGNATURE DATE

Thank you for sharing information with the Highway Construction Careers Training Program for reporting and evaluation purposes!

Have you participated in other training programs? Yes No Type of training? ___________________________________If yes, for how long? 6 months or less 6 months - 1 year 1-2 years 2 or more years

Indicate the number of dependents under the age of 18 living with you in your household:

1 2 3 4 5

6 7 8 9 or more None

1/2017