:*
ex. 1234
:*
ex. mm/dd/yyyy
:*
:
:*
:*
ex. 904-555-1212
:
:*
* You must have an email address to participate in the online program. You can get a free email address account at google.com or hotmail.com. Here’s why you need an email address that is yours alone – not shared with siblings or other family members. We use your email as the unique identifier to track you through the system, notify you of any requirements to participate, and communicate about other personal information. It will be a big help to us if your email has your name in it (janejohnson@comcast.net instead of prettykitty@comcast.net.)
:*
:
:*
:*
:*
:
:* Female
Male
:* Am. Indian/Alaskan
Native
Asian
Black
Pac. Islander
White
Multi-racial
:* Hispanic
Non-hispanic
:
* Yes
No
:* US Citizen/Naturalized
Lawful Alien/Refugee
:* 12/GED
AA/AS/Certificate
BA/BS/Doctorate
:*
* None
Dental Hygiene
Emergency Medical Services (EMS)
Health Information Management
Medical Laboratory Technology
Registered Nursing
Opthalmic Technician
Physical Therapist Assistant
Radiation Therapy
Radiography
Respiratory Therapy
:
*
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
*
*
* Single head of household 2-parent
* Yes No
* Yes No
*
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
* Yes No
*
*
*
*
ex. xx.xx
* Still Employed
Layoff (permanent or temporary)
Fired
Quit

ex. mm/dd/yyyy
* Yes No
* Yes No
* Yes No
* Not Applicable
Less than 180 days
180 or more days
Yes No
Yes No
Yes No
Yes No
:
*