QCUL INTAKE FORM
QCUL Program you are applying for:
EA2
Youth Build
Nicor
ComEd
IL Pre-apprenticeship
Solar Program
Not sure
Basic Information
Date of Intake
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender
*
Male
Female
Non-binary
Prefer not to answer
Marital Status
*
Single
Divorced
Married
Widow
Emergency Contact Name
First Name
Last Name
Emergency Contact Email
example@example.com
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Education and Employment Information
Education Qualification
*
Less than High School
High School Diploma / GED
Some college or Vocational School
Vocational
Associate Degree
Bachelor's Degree
Masters Degree
Doctoral
Employment Information
*
Full-time Employed
Part-time Employed
Unemployed
Employed but received notice of termination /layoff
Are you currently enrolled at school?
Yes
No
If yes, please provide the name of the school:
Any Construction Experience?
No experience
1-2 years
3-5 years
5+ years
Journeyman Status
Demographic Information
Race
*
American Indian or Alaskan Native
Asian
Black or African American
Hawaiian Native or Pacific Islander
White
Multi racial
Other
Ethnicity
*
Hispanic / Latino
Non-Hispanic
Disability (if any)
*
Yes
No
Prefer not to answer
Veteran Status
*
Yes
No
English Proficiency
*
Yes
No
Other
How would you describe your housing situation
Stable Housing
Temporary housing
Homeless
Are you eligible / receiving any of the following?
Unemployment Insurance
Food Stamps or Suppl. Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
Supplemental Security Income (SSI)
State or Local Welfare (General Assistance)
Social Security Disability (SSDI)
I hereby certify that the above information is true and accurate to the best of my knowledge and belief. I understand that if I intentionally provide inaccurate information, I may be terminated from the program and may be subject to legal penalties.
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