Manufacturing Academy Student Information

Quarter

Year

Location

Participant Information

First Name

Middle Initial

Last Name

Email Address

Phone Number

Cell Phone

Home Phone

State ID/DL Number

ID State

SSN

*SSN required for eligibility purposes

Physical Address

If homeless, please enter the best address/point-of-contact.

Apartment/Condo/Unit #

City

State

Zipcode

County

Check if Mailing Address is same as Physical Address

Mailing Address

Mailing City

Mailing State

Mailing Zipcode

Mailing County

Over 18?

If under 18 years of age, please provide name and email of parent/guardian.

Emergency Contact Name

Emergency Contact Cell

Emergency Contact Email

Relationship with Emergency Contact

Clothing Size

Do you have a laptop /pc with a web camera?

Demographics

Gender

Date of Birth

mm/dd/yyyy

Race

Ethnicity

Veteran Information

Veteran Status

Are you currently enlisted in the military?

Are you registered for Selective Service?

Has your spouse, parent or partner ever served in the military?

Please select the military benefit status that applies to you

Career Interests/Availability

Do you have a valid Driver's License?

Manufacturing Career Interest (specific job/position or company):

Do you want to enter an apprenticeship?

Referral Information

How did you hear about Manufacturing Academy?

Other - How did you hear about MA?

Have you attended an info session?

Location of info session?

What is the email address of your high school counselor?

If applicable

What is the direct phone number of your high school counselor?

If applicable

Additional Background Information

The following questions are to help AJAC staff determine if there are any additional community referrals and/or financial programs available to support your participation in the program. Answers are voluntary and will not impact enrollment into the program.

Disability - do you have any disabilities to consider?

Criminal Background / Offender Status

Are you a United States citizen?

If you answered no to the last question, are you authorized to work in the US?

Have you been convicted of a felony in the last 10 years?

Foster System Involved?

Have you completed the FAFSA/WAFSA in the last year?

Has anyone in your household worked in agriculture in the last two years?

Income Level/Prior Employment

Marital Status

Are you the head of your household?

Total number of people in your household:

How many children do you have?

How many children do you care for other than your own?

Income status helps us determine eligibility for financial aid. This is typically determined by family size and household income. Please help us determine by supplying the most accurate.

* FPL stands for Federal Poverty Level.

What is your gross income?

Income Level

Income Source in the last 12 months. Check all that apply:

Hold Ctrl to select multiple options.

If you are currently working, please list your employer. If you are not currently working, please type "Not Applicable."

Have you worked in the past three months?

If yes, where?

Education History

Highest Grade Completed?

Have you completed Algebra 1?

If still in high school, what School District are you currently enrolled in?

Grade Point Average?

Individualized Education Program or Known Learning Disability in High School?

Transportation/Other Barriers

Most frequently used transportation:

What do you feel are the barriers that might prevent you from getting or keeping the job you want? Check all that apply:

Hold Ctrl to select multiple options.

Other Barrier

Optional: What accommodations do you need to succeed in the classroom/workplace?

LinkedIn URL

Optional Resume Upload

Contact Information