Application for Low Voltage Training Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Number * (###) ### #### Email Address * Are you currently employed? * Yes No If currently employed, where? * Job History Previous Employer Name * Dates * Position * Reason for Leaving * Job description Education Highest Grade Level Achieved * School * How did you hear about this program? * Do you have reliable transportation? * Yes No Criminal Background Have you ever been convicted of a crime? * Yes No If yes, please briefly explain the nature of the offense. * Put N/A if this does not apply to you. Are you currently facing any criminal charges? * Yes No Are you on parole or probation? * Yes No If yes, please provide the name and contact number of assigned reporting officer. Assigned reporting officer name * Put N/A if this does not apply to you. Assigned reporting officer phone * Put N/A if this does not apply to you. Are you authorized to work lawfully in the United States? * Yes No To fully qualify for any job placement or free skills training opportunities, all individuals must voluntarily participate in 12 months of case management with the Zan W Holmes Jr. Community Outreach Center. * I do not have any medical ailments, physical limitations, or mental disabilities that will affect my ability to participate in the low voltage program. I forever release Zan W Holmes Jr. Community Outreach Center from any and all claims and causes of action that they or their representatives now have or may have in the future for personal injury, property damage or wrongful death occurring to me, arising out of participation in the low voltage program. PHOTO CONSENTSubmission of this form gives Zan Wesley Holmes, Jr. Community Outreach Center permission to capture and display photos of the event and its participants for professional promotional purposes. We own all rights to photos taken. * I agree COVID-19 WAIVER I acknowledge that I must comply with all set procedures by Zan W Holmes Jr. Community Outreach Center to reduce the spread of all Covid variants while on the premises. I attest that I hereby release and agree to hold Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the center, or that may otherwise arise in any way in connection with any services received from Zan Wesley Holmes Jr Community Outreach Center or any other collaborating partner. I understand that this release discharges Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner have against our organizations with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services from Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner This liability waiver and release extends to the center together with all owners, partners, and employees. * I agree By typing your name in the “Applicant Typed Signature” box, we will accept this application and your typed name as equivalent to you actually signing this application. Typing your name will act as your signature. Applicant Typed Signature: * Date * By submitting this application, you swear that all information provided is true and that you will abide by everything to which you have agreed. Thank you for applying to participate in our Low Voltage Job Training Program. Contact Darrylynn Dean at darrylynn.dean@zwhjcoc.org with any questions you may have.
