1.Full Name

2.Address

Address

Address 2

City/Town

State/Province

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code

County

Email Address

Phone Number

3.Date of Birth

4.Ethnicity

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Another race

5.What is the highest level of education you have completed?

Less than high school

High school diploma or GED

Some college, no degree

Associate degree (e.g., AA, AS)

Bachelor’s degree (e.g., BA, BS)

Some graduate school, no degree

Graduate or professional degree (e.g., MA, MS, MBA, JD, MD, PhD)

6.Sex

Female

Male

Non-binary

Prefer not to answer

7.Are you a veteran of the U.S. Armed Forces?

Yes

No

8.Employment Status:

Employed full-time

Employed part-time

Unemployed

Self-employed

Student

Other (please specify)

9.What is your current hourly wage (if employed)?

$1-10

$11-$20

$21+

Not currently employed

10.What is your total household income?

Less than $20,000

$20,000 to $34,999

$35,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $149,999

$150,000 or More

11.Are you interested in training for any of the following positions? (Please only select one)

EKG Technician

Patient Care Technician

Medical Assistant

12.Have you ever been convicted of a crime (felony or misdemeanor excluding traffic offenses)?

Note: A response will not automatically disqualify you. This information helps us better understand your situation and ways we may offer assistance.

Yes

No

Other (please specify)