Tri-C WIT Program Registration

* fields are required

First name: *

Last name: *

Address: *

City: *

State: *

Zip code: *

Phone number: *

Additional phone number:

Email address: *

Social media handles:

Preferred method of contact: *

Phone
Text
Email
Social media

Emergency contact: *

Relationship: *

Phone number: *

Tri-C S-Number:

Age: *

Marital status: *

Do you have children/dependents living with you?: *

Yes
No

If yes, list the number of children/dependents who live with you and for whom you have custody or joint custody.

Number :

Their age(s):

Are you a veteran?: *

Yes
No

Do you have an immediate family member who is a veteran?: *

Yes
No

If yes, who?:

Do you have a high school diploma?: *

Yes
No

Do you have a GED?: *

Yes
No

What is the highest level of education you have achieved? : *

Are you new to Tri-C (first time enrolled)?: *

Yes
No

If you do not have a college degree, have you ever taken college courses?:

Yes
No

Where:

And when:

Have either of your parents completed a Bachelor’s degree (4+ years)?: *

Yes
No

Are you currently employed?: *

If employed, employer's name:

Job title:

Hourly wage:

If you are not currently employed, in what career field is your previous work experience?:

When were you last employed?:

Please select the income bracket that applies to your family’s estimated monthly gross income.: *

Number of persons supported by this income: *

Are you a returning citizen (incarceration)?: *

Yes
No

Are you or have you ever been a victim of abuse or domestic violence?: *

Yes
No

Have you ever witnessed abuse or domestic violence in your home?: *

Yes
No

Do you have a history of substance abuse?: *

Yes
No

How did you hear about the WIT program? (Please be specific.): *

Do you have internet access at home?: *

Yes
No

Do you have access to a desktop computer or a laptop for your regular use?: *

Yes
No

What do you wish to achieve from the WIT program?: *

Job
Enter college
Enter technical training program
Other (Explain below)

If you selected "other", please explain.:

Have you ever enrolled in the WIT program before?: *

Yes
No

*If yes, did you complete the program?:

Yes
No

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