Enrollment Application – Online Workforce Training

How did you hear about us? *

Name *

First

Middle

Last

Gender *

Male
Female

Phone Number *

Email *

Date of Birth *

SSN# *

Address Line 1 *

Address Line 2 *

City *

State

Zip Code *

Country *

Do you have a valid driver's license or photo ID? *

Yes
No

Ethnicity / Race *

Primary Language *

Secondary Language

Name of High School Attended *

Date of Last Year in High School *

Year of High School graduation.

Highest Education Level Completed *

Employment Status *

Name of Previous Employer *

Job Title *

Start date of previous employment *

End date of previous employment *

Last hourly rate of pay *

Reason for leaving *

Do you have any work skills or strength? *

Yes
No

Please list skills or strength. *

Have you ever been convicted or have a pending sexual assault offense? *

Yes
No

Are there any personal barriers which make it difficult to get or keep a job? *

Yes
No

Please list the barriers. *

Are there any transportation barriers which make it difficult to get or keep a job? *

Yes
No

Please list the barriers. *

Are there any family barriers which make it difficult to get or keep a job? *

Yes
No

Please list the barriers. *

Please select an industry certification training course. *

Certified Medical Billing and Coding (CBCS)
Certified Medical Administrative Assistant (CMAA)
Certified Pharmacy Technician (CPhT)
Certified EKG Technician (CET)
Certified Heating, Ventilation & Air Conditioning Technician & Dispatcher (HVAC)
Certified Residential Building Code Inspections (IRC)

Are you participating with a public or private employment training agency? *

Yes
No

Are you registered with a workforce center/commission? *

Yes
No

Are you actively receiving SNAP services? *

Yes
No

Are you an ABAWD (Able-bodied Adults Without Dependents)? *

Yes
No

SNAP E&T Voluntary Participation Agreement

The purpose of AimHigh Education's SNAP E&T program is to provide you with accessibility to attain skills and earn industry certifications through Apprenticeship and Vocational Workforce Training programs that will help position you for an entry-level professional career or advance into high-demand and high wage paying jobs if you are already employed. These services will be provided at no cost to you. These services are funded by the Supplemental Nutrition Assistance Program (SNAP) and participating agencies. Should you choose to take advantage of this opportunity, you may also qualify for financial supportive service assistance with late rental / utility payments, transportation, child care, and other costs related to participating. This is a voluntary program. You are not required to participate in order to continue receiving SNAP benefits. If you would like to be a part of this program, please sign the statement below: (1) I understand that this is a voluntary program and does not affect my SNAP benefits. (2) I understand that while this is a voluntary program, I agree to fully participate in order to increase my chances of finding a job or getting a better job.

Do you wish to participate in the SNAP E&T program? *

Yes
No

Date *

Participant Signature *

Are you a dislocated worker? *

Yes
No

1. Are you currently unemployed? *

Yes
No

2. Do you need weekly childcare assistance, during the set-aside time for online learning? *

Yes
No

If you said yes to 2, please provide your monthly child expenses. *

Please provide a copy of your most recent childcare statement/receipt *

Click or drag a file to this area to upload.

3a. Do you have access to a computer? *

Yes
No

3b. Do you have Internet Access? *

Yes
No

If you answered yes to 3b, please provide the amount spent on Internet *

If you answered yes to 3b, please attach your latest Internet bill *

Click or drag a file to this area to upload.

4a. Monthly Household Income *

4a. Source of Monthly Household Income *

4b. Additional Monthly Household Income

4b. Source of Additional Monthly Household Income

4c. Additional Monthly Household Income

4c. Source of Additional Monthly Household Income

5. Does your monthly income exceed the federal poverty guidelines for the family size? *

Yes
No

See Chart (Click to see)

6. Monthly Household Living Expenses

7. Does your monthly Household income exceed the monthly living expenses? *

Yes
No

8a. What is your Monthly Water Expense?

Please provide a copy of your most recent Water Bill?

Click or drag a file to this area to upload.

8b. What is your Monthly Electric Expense?

Please provide a copy of your most recent Electric Bill?

Click or drag a file to this area to upload.

9. Are you currently behind on rent payments? *

Yes
No

Rental / Utility Assistance Declaration

The purpose of Rental / Utility Assistance is to provide you with financial assistance and resources to help you resolve rental / utility arrears only. Rental / Utility Assistance are supportive services that we provide to eligible participants that are actively engaged in an Apprenticeship or Vocational Workforce Training program. Supportive Services serve financially to assist participants that are encountered with financial hardships that can create a barrier to successfully developing skills and attaining professional industry certifications. I understand that rental / utility assistance is only for late or missed rent payments. (1) I understand that my continued eligibility for rental /utility assistance is contingent upon my active participation and responsive communication with staff, while in my Workforce Training program. (2) I understand that my eligibility for rental /utility assistance does not imply nor express that AimHigh Education Technologies, LLC will resolve my full balance of rental / utility arrears.

Rental / Utility Assistance Participation *

I understand the above Rental / Utility Assistance Declaration and agree to be considered for Rental / Utility assistance.
I do NOT wish to be considered for Rental / Utility Assistance.

Download Form (Click to download)

Consent for Release of Personal Records by Executive Agencies

To Whom It May Concern: I have sought participation and assistance from AimHigh Education Technologies on a matter that may require the release of information maintained by your agency, and which may be prohibited from dissemination under the Privacy Act of 1974. I hereby authorize you to release all relevant portions of my records or to discuss information with AimHigh Education Technologies, or any member of it’s staff until the matter is resolved.

Authorization *

Yes
No

Name of Landlord/Agency *

Signature *

I certify under penalty of perjury that the above information is true and correct to the best of my knowledge.

Date *

Participant Name *

Participant Signature *

Case Management Only

Did the student participant successfully completed training course?

Yes
No

Did the student participant earn an industry certification?

Yes
No

Is the student participant employed with industry certification?

Yes
No

Are we providing job placement services with the student participants?

Yes
No

Is the student earning a second certification?

Yes
No

Which certification did the student earn?

HVAC Technician & Dispatcher
Medical Coding & Billing
Medical Administrative Assistant
Residential Building Code Inspections
Solar PV Installer Technician

Name of Case Manager: