Participant Enrollment Form Captains License Training

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Captains License

Complete the following application to be considered for the training. You will be contacted by The Education Exchange to discuss the training and review your application.

Thank you for your interest in our Captains License Training Program! This is program open to Rhode Island residents who have been negatively affected by Covid-19 and are looking to improve their skills in the workforce.

Our next training will start sometime early 2023, and will run for 2 weeks, Monday through Friday from 9AM to 5PM. The program will take place online and/or in person at the Education Exchange in Peace Dale (South Kingstown, RI). to be eligible participants should have a background in boating and trackable sea time prior to class enrollment.

Please complete the following application to be considered for the training. You will be contacted by the Coordinator to discuss the training and review your application.

Email *

Briefly describe your boating experience (hrs. at sea, personal watercraft usage or fishing boat time) *

Phone Number *

Last Name *

First Name *

Date of Birth *

YYYY

Gender *

Female

Male

Prefer not to say

Social Security #

Race/Ethnicity *

Hispanic/Latino

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or more races

Prefer not to say

Required

Citizenship Status (check all that describe you)

U.S. Citizen

Born in Puerto Rico or Virgin Islands

Born abroad of U.S. Parents

Foreign born - not a citizen

Foreign born - Naturalized Citizen

Refugee

Prefer not to answer

Your first language

English

Other:

Clear selection

Other languages spoken

Main language spoken at home

Do you read and write in your first language

Yes

Clear selection

Country of Origin

Date of Arrival in the US

YYYY

Name of last school attended

Location of last school (city, state, and country)

Last year you attended school

Education History. Mark all boxes that apply to each grade. Mark Incomplete if you missed more than 3 months of a year for any reason. If you repeated the grade, check repeated

Complete

Incomplete

Repeated

In U.S.?

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Highest Education Level Completed

Secondary Diploma

Secondary Equivalency (Ex: GED)

Some post-secondary education, no degree

Post-secondary education or professional degree

Are you currently attending school or training?

Yes

Clear selection

If yes to previous question, please provide name of other program or class.

Employment Status (please check all that describe you)

I am a full time worker

I am a part time worker

I am unemployed

I am a dislocated worker (I have received notice of pending or actual layoff from a job or military)

I am not in the labor force (not employed and not seeking employment)

I am a seasonal farmworker

I am a migrant farmworker

Life Circumstances (check all that describe you)

Cultural Barriers

Disabled

Displaced Homemaker

Low Income

English Language Learner

Ex Offender

My public assistance(TANF) will run out in the two years

I have been in foster care and am under age 22

Homeless

I have been unemployed for 27 weeks or more

Low Literacy Levels

Migrant Farmworker

Seasonal Farmworker

Single Parent or Guardian

I am a dislocated worker

I am in a correctional facility

I am in community corrections

I am in an institution

None of these apply to me

Street Address *

City *

State *

County *

Zip Code *

Which of the following do you have at home so we can contact you and/or connect you to services? (Check all that apply)

Computer with camera and microphone

Computer without camera

Mobile phone

Home phone

Internet Access

Printer

Scanner

I give permission to the Rhode Island Department of Education to use the information collected in the Comprehensive Adult Literacy Information System for data matching, research and evaluation as long my information is never made public. (Virtually sign and date) *

I give permission for my educational record to be released to other institutions for education purposes. (FERPA) (virtually sign and date) *

Please provide name and phone number for an emergency contact.

My criminal record is a barrier to employment.

Agree

Disagree

Prefer not to answer

Clear selection

I receive public assistance.

Yes

Prefer not to answer

Clear selection

What kind of public assistance do you receive? (check all that apply to you)

Food Stamps

WIC

Other

Are you a parent/caregiver/guardian of a student in the local school system?

Yes

Clear selection

Have you ever had training for work through ORS (Office of Rehabilitation Services)?

Yes

Clear selection

Do you have any physical limitations or health concerns that your teacher should know about so that you can learn more easily in class?

Yes

Clear selection

If yes to previous question, please describe.

Do you have learning disabilities or difficulties?

Yes

Clear selection

If yes to the previous question, please describe.

I have a diagnosed disability.

Yes

Clear selection

I know what kind of accommodations I will need to participate in class.

Yes

Clear selection

If yes to previous question, please describe.

I would like to get more information about possible accommodations.

Yes

Clear selection

How did you learn about this program?

Friend or Family member

Court or Court Order

Newspaper or magazine

Pamphlet or Brochure

Radio or TV

Catalog

Employer

Website

None

Agency Referral

Union

Other:

U.S. Selective Service Notification **(Only applicable to Males, Ages 18-25)

U.S. Selective Service Notification (Virtually sign and date)

Clear form

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