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

Which courses do you plan to take? If choosing more than one, press and hold the “ctrl” button on keyboard when making your choices

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? If choosing more than one, press and hold the “ctrl” button on keyboard when making your choices

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? If choosing more than one, press and hold the “ctrl” button on keyboard when making your choices.

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