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PhoneREQUIRED

AddressREQUIRED

Street Address Address Line 2 City State ZIP Code

Date of BirthREQUIRED

Month

Day

Year

Highest Grade CompletedREQUIRED

Attended/Did not complete grade 12

High School Diploma or Equivalency (GED)

Some Postsecondary (College) Education, no degree

Postsecondary (College) Education Degree

No Schooling

Last Pennsylvania Public School AttendedREQUIRED

*Type NA if you did not attend school in Pennsylvania

Program InterestREQUIRED

*Select your primary program of interest (Only One)

GED Preparation

English as a Second Language (ESL)

Adult Basic Education

Citizenship Class

Tutor

Nurse Aide (CNA)

Community Health Worker Training

Forklift Operator Training

Customer Service & Sales

Digital Literacy/Computer Training

Success Academy - Job Readiness training for Women & Girls

ServSafe(R) Food Handler

Environmental Technician Training

Emergency Medical Technician Training (Summer only)

Employment StatusREQUIRED

Employed Full-time

Employed Part-time

Not employed, looking for work

Not employed, not looking for work

Unavailable for work

When are you available?REQUIRED

Daytime

Evening (Online GED class & tutors only)

Both

Do you have internet access at home?REQUIRED

Yes

No

What type of device would you use for online learning at home?REQUIRED

Desktop computer

Laptop computer

Tablet (iPad, Fire, Samsung)

Chromebook

Smartphone

I do not have a device

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School Counselor

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Worksite or Employer

Referred by PA CareerLink

Previously attended

Court mandated

Referred by another agency

Other

Other:

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Employment Skills Center
29 South Hanover Street
Carlisle, PA 17013

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