Participant Enrollment Form Captains License Training
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 *
Gender *
Social Security #
Race/Ethnicity *
Citizenship Status (check all that describe you)
Your first language
Clear selection
Other languages spoken
Main language spoken at home
Do you read and write in your first language
Clear selection
Country of Origin
Date of Arrival in the US
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
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
Are you currently attending school or training?
Clear selection
If yes to previous question, please provide name of other program or class.
Employment Status (please check all that describe you)
Life Circumstances (check all that describe you)
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)
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.
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I receive public assistance.
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What kind of public assistance do you receive? (check all that apply to you)
Are you a parent/caregiver/guardian of a student in the local school system?
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Have you ever had training for work through ORS (Office of Rehabilitation Services)?
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?
Clear selection
If yes to previous question, please describe.
Do you have learning disabilities or difficulties?
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If yes to the previous question, please describe.
I have a diagnosed disability.
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I know what kind of accommodations I will need to participate in class.
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If yes to previous question, please describe.
I would like to get more information about possible accommodations.
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How did you learn about this program?
U.S. Selective Service Notification **(Only applicable to Males, Ages 18-25)
U.S. Selective Service Notification (Virtually sign and date)
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