Career Education Registration Form
WIOA Grant Funding
Participant Name
*
First Name
Last Name
Participant Email (this email will be used to access classes--must be active email that participant can access)
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Course Registration
Please indicate which courses to register you for. You may select more than 1 course.
Course(s) that participant is registering for:
*
Personal Career Qualities (Thursdays 2-3 pm)
Job Preparation (Fridays 2-3 pm)
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Demographic Information
Please answer all questions to the best of your ability.
Participant date of birth
*
-
Month
-
Day
Year
Date
Participant Sex/Gender
*
Male
Female
Choose not to self-identify
Participant Ethnicity
*
Hispanic or Latino
American Indian or Alaska Native
Asian
Black or African America
Native Hawaiian or Other Pacific Islander
White
Participant has a documented intellectual or developmental disability
*
Yes
No
Please input participant's primary diagnosis
*
Participant receives Local Mental Health Agency services
*
Yes
No
Participant receives services under State Medicaid HCBS Waiver (CLASS, HCS, TXHml, etc)
*
Yes
No
Participant employment status
*
Employed-working
Employed-furloughed
Unemployed
Participant has been long-term unemployed for 27 or more consecutive weeks
*
Yes
No
Please enter participant's most recent work experience (job title)
*
Number of months employed in most recent job
*
Veteran Status
*
Yes
No
Veteran status unknown
Highest Educational Level completed
*
High school degree obtained
High school equivalency obtained
Post completion of IEP
Completed 1 or more years of post-secondary education
Obtained nondegree post-secondary technical or vocational certificate
Obtained Associate's degree
Obtained Bachelor's degree
Obtained Master's degree or higher
Current school status
*
Attending high school or 18+ program
Attending post-secondary school
Not attending school, graduate
Participant is current customer of TWC Vocational Rehabilitation
*
Yes
No
SSI or SSDI
*
Participant receives SSI only
Participant receives SSDI only
Participant receives both SSI and SSDI
Neither
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Required Eligibility Documentation
To attend classes under WIOA grant funding, you must upload copies of the following documents.
Upload copy of participant's Social Security Card
*
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Upload copy of participant's State ID or Driver's License
*
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Workforce Innovation and Opportunity Act (WIOA)
For individuals to participate in Workforce Innovation and Opportunity Act programs, they must be authorized to work in the United States. I have submitted the following documents to establish identity: 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address. 2. Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States. I certify that the information is true and accurate, and understand that the above information, if misrepresented or incomplete may be grounds for immediate termination or penalties as specified by law
Signature of participant or guardian that WIOA statement is accurate
*
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Please indicate which documentation for disability status you will upload
*
High school IEP
Doctor's assessment with diagnosis indicated
Nursing assessment (Medicaid HCBS waiver)
Guardianship paperwork with diagnosis indicated
Upload documentation of participant's diagnosed disability
*
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of
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Signature of client or guardian attesting that the above information is accurate.
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Submit
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