Home Phone #
Alt Phone #
Are you currently employed? YesNo
Do you have a valid drivers license? YesNo
What is your mode of transportation?
Employment Dates (from-to)
Reason for leaving
Dates of Attendance (from-to)
Dates of Attendance (from-to)
GED Completion Date (if applicable)
Last Grade Completed?
If you do not have a GED, will you commit to working towards attaining your GED while at MCSC? YesNo
Please tell us why you'd like to join the MCSC team
Are you currently receiving government assistance? If yes, please detail below
What is your estimated annual income? $0-11,000$11,500-19,000$19,500-24,500$25,000-31,5000$32,000-40,000
Are you on probation? YesNo
(By answering yes it will not disqualify you from the program)
REFERRAL SOURCE: How did you hear about MCSC?
Please read and initial to confirm your understanding and agreement to the terms noted.
I understand that every applicant has to complete the intake process before acceptance into the program. The intake process includes: (1) Submitting application; (2) One-on-One Interview; (3) Pre-Screening based on career goals; (4) Eligibility.
I understand that Milwaukee Community Service Corps is a drug free environment. I agree to remain drug free while participating in the program.
I understand that the Milwaukee Community Service Corps requires all participants to participate in a 1-week unpaid orientation.
I understand that the Milwaukee Community Service Corps requires every Corps member to participate in all classes, all work projects, and all facets of the MCSC Program once accepted and enrolled.
I understand that classroom education to obtain credentials, licenses and certifications is required by the Milwaukee Community Service Corps and that the time in education is unpaid. I accept that I will not be paid while attending classes, and will only be paid when participating in field work experience projects.
I understand that my participation in the Milwaukee Community Service Corps classes may require me to complete daily homework assigned by the instructor. I agree that I will complete the homework assigned to me by the due date indicated by the instructor. I understand that failure to complete the homework assignments may result in my termination from MCSC.
I understand that my participation in MCSC requires me to wear steel-toe boots year round and cold weather gear consisting of insulated work coveralls during winter. It is my responsibility to purchase a pair of boots before the first day of work. I understand that this personal protective equipment is my property that I may take with me after my enrollment with MCSC ceases.
I have completed this application honestly, accurately, and to the best of my ability. I further agree to the terms above.
I, authorize to disclose to, Milwaukee Community Service Corps and appropriate funding sources the following information:
The purpose of this disclosure authorized in this consent is to: Employment Program Services.
I understand that my records are protected under the federal regulations governing Confidentiality of Record, 42 C.F.R. Part 2 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. Upon request, I may receive a copy of this form.
Signature of person signing form if not applicant (if under 18, a legal guardian must sign)
Describe authority to sign on behalf of applicant
I understand and agree that I retain ownership and unrestricted use of all my photographs that are submitted to Milwaukee Community Service Corps (MCSC) for possible inclusion marketing and online applications. However, I hereby grant to Milwaukee Community Service Corps the permanent and irrevocable right to use these submitted photographs as they deem appropriate without limitation or compensation. I have obtained all needed rights and clearances to use the photographs I am submitting and assume full legal and financial responsibility for the same. I will retain copies of my photographs PRIOR to submission to MCSC so that I may make prints, etc., if I wish.
I agree and understand full well that the copies of my photographs (most likely digital files) submitted to MCSC will not be returned and they may or may not be included in the marketing and online materials at MCSC’s discretion.
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