Student Intake Form

Page 1

Thank you for enrolling in a class or program with the 1199 New England Training Fund. To be eligible for these classes or programs you must have completed your probation period at a Connecticut nursing home that contributes to the Training Fund

Personal Information

First Name

Last Name

Social Security #

Home Mailing Address

City

State

Zip Code

Cell Phone

Home Phone

Race/Ethnicity

Gender

Date of Birth

Are you a parent/guardian?

Number of Children

List ages of children under 18 (comma separated)

For assistance regarding this form, contact Angela Alfieri, AAlfieri@1199trainingfund.org

Page 2

Nursing Home Information

Nursing Home Name

Job Title

Shift

Date of Hire

Training Information

Course Information

Subject to receive tutoring

Other subject

Semester Enrolling For

Do you have a high school diploma?

Last Grade Completed

Which of the following devices do you have access to at home?

Do you have a reliable internet service which will allow you to do online courses or training?

How often do you use a computer?

What do you use a computer for?

For assistance regarding this form, contact Angela Alfieri, AAlfieri@1199trainingfund.org