Empowering Your Future: Workshop
Customer Registration
Name
*
First Name
Last Name
Preferred name
Zip Code
*
ex: 60435
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your phone receive text messages
*
Yes
No
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What sex were you assigned at birth
*
Please Select
Male
Female
Prefer not to answer
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Race
*
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer Not To Answer
Employment Status
*
Currently Employed
Collecting Unemployment
Currently Not Employed
Highest Level of Education
*
Graduate's Degree (Master's or Higher)
Bachelor's Degree or Equivalent
Associate's Degree
Some College
High School Graduate/GED
Less than High School
Would you mind telling us your sexual orientation
*
Another Sexual Orientation
Bisexual
Gay, Lesbian, or Homosexual
Straight/Heterosexual
Prefer Not to Answer
Are you currently working toward a degree, certificate or other training credential?
*
Yes
No
Do you have a disability?
*
Yes, I have a disability
No, I do not have a disability
Prefer Not to Answer
Challenges to gaining and keeping employment
*
Transportation
English Language Learner
Offender, Misdemeanor
Offender, Felon
Single Parent
Drug/Alcohol Dependency
Homeless
Facing Substantial Cultural Barriers
None
Other
Are you currently receiving any of the following services?
*
Food Stamps (SNAP)
Supplemental Security Income (SSI)
Temporary Aid to Needy Families (TANF)
Social Security Disability Insurance (SSDI)
None
Are you a Veteran, Qualified Spouse or Transitioning Service Member?
*
Veteran
Qualified Spouse
Transitioning Service Member
Not a Veteran, Qualified Spouse or Transitioning Service Member
How did you learn about us?
*
Internet
Friend/Relative
Joliet Junior College
IL Dept. of Human Services
Court/Probation
Newspaper/Radio
IDES / Unemployment Office
Joliet Job Corps
Church/Pastor
Facebook/LinkedIn/Twitter(X)/Social Media
Veterans Assistance Commission
Other
Would you like to receive our Monthly Newsletter with information on upcoming workshops, job fairs, and community events?
*
Yes
No
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