FourBlock Registration Form

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Thank you for your interest in our Career Readiness Program! The dates for the Spring 2019 term are below. Please fill out the form at the bottom to begin the application process.

*Online Course / MOOC
Ongoing

Atlanta, GA
Cohort 1: 1/23 - 4/24 | Wednesdays| 6:00-9:00 PM
Cohort 2: 1/24 - 4/25 | Thursdays | 6:00-9:00 PM
Registration Deadline: 1/17

Austin, TX
3/27 - 5/15 | Wednesdays | 6:00-8:00 PM
Registration Deadline: 3/11

Bellingham, WA (PNW Region – Western Washington University)
1/10 - 3/14 | Thursdays | 5:30-7:30 PM
Registration Deadline: 1/2

Boston, MA
2/12 - 4/23 | Tuesdays | 6:00-8:00 PM
*No class 3/19
Registration Deadline: 2/2

Bothell, WA (University of Washington Bothell)
Cohort 1: 1/11 - 3/1 | Fridays | 11:00 AM-1:00 PM
Cohort 2: 4/5 - 5/17 | Fridays | 11:00 AM-1:00 PM
Registration Deadlines: 12/21/18 (Cohort 1) 3/22 (Cohort 2)

Charlotte, NC
3/13 - 5/1 | Wednesdays | 6:00-8:00 PM
Registration Deadline: 3/4

Dallas, TX
2/12 – 4/2 | Tuesdays | 6:00-8:00 PM
Registration Deadline: 1/28

Denver, CO
3/27 – 5/15 | Wednesdays | 6:00-8:00 PM
Registration Deadline: 3/11

Los Angeles, CA
3/27 - 5/15 | Wednesdays | 6:00-8:00 PM
Registration Deadline: 3/11

New York City, NY
2/6 - 4/24 | Wednesdays | 6:00-8:00 PM
*No class 3/20
Registration Deadline: 1/27
A waitlist has been started for SP19

Philadelphia, PA
2/5 - 4/23 | Tuesdays | 6:00-8:00 PM
*No class 3/5
Registration Deadline: 1/26

San Diego, CA
2/21 - 4/11 | Thursdays | 6:00-8:00 PM
Registration Deadline: 1/28

San Francisco, CA
3/27 - 5/15 | Wednesdays | 6:00-8:00 PM
Registration Deadline: 3/11

Seattle, WA
3/27 - 5/15 | Wednesdays | 6:00-8:00 PM
Registration Deadline: 3/11

Tacoma, WA
2/12 - 4/2 | Tuesdays | 5:30-7:30 PM
Registration Deadline: 1/28

Washington, DC
1/29 - 4/9 | Tuesdays | 6:00-8:00 PM
*No class 3/12
Registration Deadline: 1/19
A waitlist has been started for SP19

Bremerton, WA
2019 Dates TBA

Chicago, IL
Fall 2019 Dates TBA

Tampa, FL
Fall 2019 Dates TBA

Walter Reed NMMC (Bethesda, MD)
2019 Dates TBA

The information you provide is stored securely and is accessed by FourBlock Staff only as needed. It will not be shared externally in any way that can be identified with you. Documents used to confirm eligibility for programs which contain sensitive, private, and/or identifiable information will be deleted from our servers every month.

The use of your DD-214, copy of proof of identification, or appropriate proof of service will be used solely for the confirmation of your military service.

Please complete this form within 30 minutes or your session may time out. If you'd like to save your progress and come back to the form later, you can do this using the links at the top or bottom of the form.
Confirm Information




Please note that this email address will be used to create your login for accessing course material on the Canvas platform.

The information in this section is protected and does not effect your eligibility for the program
Responses are required for Gender and Ethnicity however, you may select the option that you "Do Not Wish to Disclose."  The information gathered here makes no impact on your participation or eligibility.  



Contact Information





Military History / Veteran Status









Please Confirm Your Service

Please upload your Proof of Service, using the following file name format:
LastName, FirstName_ProofofService

If you are discharged and not serving on Active or Reserve Duty - Please submit a copy of your DD-214 (Copy 1 or Copy 4 are both acceptable).  You may also submit a Proof of Service Letter which you can obtain from the eBenefits website under "VA Letters" (www.ebenefits.va.gov). 

If you are currently serving on Active Duty or Reserve/National Guard - Please provide the following:
a. Copy of your current orders
b. Copy of valid state or government-issued ID (front and back) (do not your submit your Military ID)
By submitting valid copies of your identification and current orders, you agree that your military service is in good standing and aligned with the performance and conduct that would be required to qualify for a discharge under Honorable Conditions. 

Please note:  You may black-out sensitive information not necessary for the confirmation of your proof of service and/or condition of discharge.  
Professional & Program Interests










Education

If your college isn't in this list, select "OTHER" and enter your college in the "Other University/College" field below.


ONLY enter your University/College here if it didn't appear in the menu above




If your college isn't in this list, select "OTHER", and enter your college in the "Other University/College (Additional College)" field below.


ONLY enter your University/College here if it didn't appear in the menu above



Media Release Authorization
I hereby grant permission to FourBlock Foundation to take and use photos, videos, audio, and/or other media of me for use in publicizing FourBlock Foundation. These materials may be published in digital, print, video, audio, and other media formats without any payment or other compensation.

By checking the box and entering my full name below, I understand that: 

• The materials will be used only for marketing purposes in support of raising awareness and funds for FourBlock Foundation. 

• Any funds raised from publishing will be used to support the mission of FourBlock Foundation. 

• My name may be revealed in descriptive text or commentary in connection with the material(s). 

• FourBlock Foundation may distribute the materials and my contact info to other partners, if it supports the mission of FourBlock Foundation. 

• All materials will be the property of FourBlock Foundation. 

This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. I have read this release before and I fully understand the contents, meaning, and impact of this release.