Form ETA 652 ETA 652 Job Corps Data Sheet

ETA FORM 652

OMB Control No. 1205-0025

Expiration Date: 1/31/2017

U.S. Department Labor

Employment and Training Administration

Job Corps Data Sheet

Screener Code:

OA Counselor:

Interview Date:

Application Type:

OAC Address:

Phone:

Student ID:

Name:

Sample:

Center ID:

DOB:

Place of Birth:

Race:

Sex:

Address:

Phone:

Primary Contact:

Phone:

Alternate Contact:

Phone:

Legal Resident:

US Citizen:

Alien Registration No.:

Alien Registration Exp. Date:

GED/High School Diploma:

Highest Grade Completed:

No. Months Out of School:

Currently Employed:

Previously Employed:

Earnings Per Hour:

No. of Weeks Unemployed:

Cultural Barriers:

Family Status:

No. in Family:

Est. Annual Income:

Displaced Homemaker:

Public Assistance:

Marital Status:

No. of Dependants:

Dep. Children:

Child Care:

JCC Day Care:

Allotment Eligibility:

Bilingual Program Req:

Prior Conviction:

Prior Military:

Review:

Approved:

Basic Skills Deficient:

School Dropout:

Homeless Runaway or Foster Child:

Parent:

Requires Additional Education, Vocational Training, or Career Counseling:

Remarks:

Previous Enrollment Date:

Separation Date:

Center where Separated:

Destination of Applicant after Separation:

Reason (s) for Separation:

Reason (s) for Reapplying:

APPLICANT COMMITMENT STATEMENT I understand that entrance into Job Corps is a privilege, and that only those individuals that qualify and show commitment will be accepted. The Job Corps program is a scholarship to attend a training program to enhance basic work skills that lead to quality employment with advancement opportunities. BENEFITS: Job Corps provides a safe, drug-free living environment where I can attain: Academic Education: Academic skills that I need to succeed in the work place (GED, High School Diploma, Training, College Preparation). Vocational Training: Occupational skills that I need to succeed in today’s competitive job market. Social Skills: Life skills that I need to get along well in the work place and in everyday life. Placement: Job search skills and assistance in finding a job when I complete my training.

Signature:

Date:

EXPECTATIONS: I understand that violence, drug or alcohol use, and sexual harassment are not tolerated at Job Corps. I understand that I must be drug-free upon entry, and that I will remain drug-free while enrolled. I also understand that I will be tested for drugs upon arriving at the center. I understand that I will be living in a multi-cultural environment and sharing a dormitory with other students. I understand that I will be responsible for cleaning my living area and sharing responsibility with other students to maintain a safe environment. I understand that if I have problems on center, I will contact my Center Counselor or Admissions Counselor to work out the problems. I understand that I will be given an orientation to the center rules and regulations, and that I must abide by these policies to remain in the program. I understand that in order to obtain the benefits Job Corps has to offer, I must attend classes and complete the program. I certify that my Admissions Counselor has discussed the benefits and expectations of the Job Corps program with me. If I am accepted to Job Corps, I agree that I will accept these conditions and commit to fully participate in the program.

Signature:

Date:

JOB CORPS CONSENT RECORD

The admissions counselor is to read each item on this consent form to the applicant and parent/guardian, if applicable, ensure that he/she (they) understand(s) it, and have the applicant and parent guardian, if applicable, sign the form.

I (we), the undersigned, certify that all information on the application forms is accurate.

I (we) consent to the enrollment of the above-named individual into the Job Corps.

I (we) further understand that any false statement or dishonest answers will be grounded to dismissal of the above named individual and may be punished by law.

I understand that, if I am required to be registered with the Selective Services System, I am authorizing Selective Services to register me at the age of 18. I further understand that if I am already registered, the automatic registration process will not register me again.

I (we) authorize all routine and customary physical examinations, dental work, surgical and other treatment as required by the Job Corps regulations, as well as the collection of information such as education and medical records.

I (we) authorize release of medical information to Job Corps Staff with a need for that information and to the local/or state health department when required by law.

I (we) have been provided with a personal copy of Job Corps Privacy Act statement. I (we) have read the statement and understand the contents.

I (we) have been provided information about Job Corps, life on a Job Corps center, vocational offerings, and job outlook information. I (we) have been told what Job Corps expects of me as a student. All of my (our) questions have been answered.

I (we) understand that I (we) are responsible for keeping the Job Corps center in which my son/daughter is enrolled informed of any address changes.

I (we) authorize Job Corps to gather information about my employment after participating in Job Corps training.

Signed:

_________________________________ _________________________________

Applicant Date

_________________________________ _________________________________

Parent/Guardian, if applicable Date

Student ID:	NAME:
JOB CORPS ZERO TOLERANCE FOR VIOLENCE, DRUGS and ALCOHOL CERTIFICATION Every student has the right to participate in the Job Corps program without being subjected to violence or drug abuse. I have been informed about Job Corps’ Zero Tolerance for violence policy and agree that while I am enrolled in the Job Corps program I will abide by it. I understand that if I commit one or more of the following offenses I will be immediately removed from the program, and will lose the chance to be present for a Center Review Board. However, I will be able to make a written statement on my behalf, and will be given the opportunity to appeal the decision of the board. The offenses that require automatic removal from the program are: Possession of a weapon on center or while under center supervision, including but not limited to guns or ammunition, knives of any size, explosives, or homemade weapons. Assault with the intent to do bodily harm, with or without the use of a weapon; threat of assault; or a threat to safety, including threats expressed verbally, via text, email, blog or social media. Sexual assault, with or without bodily harm. Possession or distribution of drugs on center or under center supervision. Use of drugs as evidenced by a positive drug test. Possession, consumption, or distribution of alcohol while on center or under center distribution, or abuse of alcohol. Robbery or extortion. Arson. Arrest for felony or violent misdemeanor on or off center, or conviction of a felony or misdemeanor that occurred while enrolled. Cruelty to animals. Inciting a disturbance or creating disorder. I also understand that there are other offenses that may result in disciplinary action, which may include separation from the program. I also understand that my refusal to sign the Zero Tolerance for Violence certificate will prevent my future and continued enrollment in Job Corps.
Signature:		Date:

JOB CORPS READMISSION INFORMATION READMISSION AGREEMENT I hereby apply for readmission to Job Corps. I have never before been readmitted to Job Corps. To the best of my knowledge there has been no significant change in my physical condition since I left Job Corps.
Signature of Applicant:	Date:

RECOMMENDATION OF ADMISSION COUNSELOR I have discussed with the applicant the reasons why he (she) left Job Corps and now wants to return. I have explained to the applicant the eligibility requirements for readmission outlined in Chapter 1, Job Corps Policy and Requirements Handbook. I am satisfied that the youth is sincere in his (her) desire to return to Job Corps and complete the training. I recommend that the youth is readmitted.

Signature of A.C.

Date:

Privacy Act Notice:

All request for personal information about students must be treated as requests under the Freedom of Information Act and the Privacy Act of 1974, and handled pursuant 29 CFR Parts 70 and 70a and 45 CFR Parts 160 and 164.

Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0025). Please do not submit completed forms to this address.

ETA Form 652 (Rev. 1/31/2014)

Previous versions usable

ETA 652 – Job Corps Data Sheet

Purpose: Used to collect personal information about the applicant which is needed by the Admissions Counselor to determine eligibility for the Job Corps Program. Includes the Application Commitment Statement, Job Corps Zero Tolerance for Violence and the Supplemental Medical Consent Form. Each must be signed by the applicant.

ETA Form 652 (Rev. 1/31/2014)