Form ETA 652 ETA 652 Job Corps Applicant Data Sheet

ETA FORM 652

OMB Control No. 1205-0025

Expiration Date: xx/xx/xxxx

U.S. Department Labor

Employment and Training Administration

Job Corps Applicant Data Sheet

Screener Code:

Date Application Opened: (Date new application opened in OASIS)

Date Application Completed:

Admissions Counselor:

Application Type: □ New □ Readmit

OA Address:

OA Phone:

Student ID:

Applicant Name:

Center ID:

DOB:

Place of Birth:

Race/Ethnicity:

Sex:

Applicant Address:

Email:

Phone:

Primary Contact:

Email:

Phone:

Alternate Contact:

Email:

Phone:

Legal Residency Type

Criminal History Review

□ US Citizen

□ Non-Citizen

□ Deferred Action for Childhood Arrivals (DACA)

Criminal Conviction:

Disqualifying Conviction:

Income Eligibility

Family/Household Status: □ Family Head □ Family Member □ Family Unit of One □ Unrelated Individual

No. of Dependents in Family/Household:

Est. Annual Income:

Public Assistance:

Homeless:

Foster Child:

Free or Reduced Lunch:

Victim of Trafficking:

Employment History

Employment Status: □ Currently Employed □ Employed in Previous 6 Months □ Unemployed

No. of Weeks Unemployed:

UC Eligible Status:

Current Employer:

Industry Type:

Job Title:

Months Employed:

Hourly Wage:

Est. Hours Per Week:

Previous Employer:

Industry Type:

Job Title:

Months Employed:

Hourly Wage:

Est. Hours Per Week:

Military Experience

Received Social Services:

Prior Military:

Eligible Veteran Status:

Campaign Veteran:

Disabled Veteran:

TANF:

Date of Military Separation:

Transitioning Service Member:

Covered Person Entry Date:

Homeless Veteran:

SSI/SSDI:

GA/RCA:

Education

High School Diploma/HSE:

Diploma Type:

School Dropout:

Highest Grade Completed:

No. Months Out of School:

Basic Skills Deficient:

Runaway/ Foster Care:

ELL Req:

Name of Last High School Attended:

City, State

Requires Additional Education, Career Training, or Workforce Preparation Skills:

Cultural Barriers:

Family/Child Care

Marital Status:

Allotment Eligibility:

Dependent children:

Child Care Arranged (Y/N):

Internal Review

Review:

Approved:

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 training program to develop or improve job and employability skills that lead to quality employment with advancement opportunities. ACKNOWLEDGEMENT OF 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 workplace (High School Diploma, High School Equivalency, and post-secondary preparation). Career Training: Occupational skills that I need to succeed in today’s competitive job market. Employability Skills: Workforce preparation skills that I need to be successful in a job and in everyday life. Placement: Job search skills and assistance in finding a job when I complete my training.

Applicant Signature:

Date:

ACKNOWLEDGEMENT OF 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 multicultural 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 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 I understand the expectations of the Job Corps program. If I am accepted to Job Corps, I agree that I will accept these conditions and commit to fully participate in the program.

Applicant Signature:

Date:

JOB CORPS APPLICANT AND PARENT/GUARDIAN CONSENT RECORD The admissions counselor must 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 grounds for 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, career training offerings, and job outlook information. I (we) have been told what Job Corps expects of me (my son/daughter) 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 I am (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. I (we) authorize Job Corps to contact me (us) via phone calls, emails and/or text messages to gather information about my Job Corps application, program participation and post enrollment experiences.
Applicant Signature:	Date:
Parent or Legal Guardian Signature:	Date:

Student ID:	NAME:
JOB CORPS ZERO TOLERANCE STUDENT CONDUCT SYSTEM 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. Arrest for felony or violent misdemeanor on or off center, or conviction of a felony or misdemeanor that occurred while enrolled. Robbery or extortion. Arson. Cruelty to animals. Inciting a disturbance or creating disorder. I understand that there are other offenses that may result in disciplinary action, which may include separation from the program. I understand that my refusal to sign this Zero Tolerance certificate will prevent my enrollment in Job Corps.
Applicant Signature:		Date:

RECOMMENDATION OF READMISSION I have discussed with the applicant the reasons why he/she left Job Corps and now wants to return. I have reviewed with the applicant the requirements for readmission as outlined in Job Corps policy. I am satisfied that the applicant is sincere in his/her desire to return to Job Corps and complete the training. The applicant states they have never been readmitted to Job Corps, and that if new information shows that the applicant has previously been readmitted they are not eligible for enrollment. I recommend that the applicant is readmitted.

Signature of Admissions Counselor

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. 3/2/2020)

Previous versions usable

ETA 652 – Job Corps Applicant 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. 3/2/2020)