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DESE Substitution Certification Enrollment Form

Today's Date

Program Type

Name of Program

Rapids & ONET Code

STUDENT INFORMATION

Last Name

First Name

Middle

Birthdate

Age

Sex

Sex
A
B

Street Address

City

State

ZIP Code

Contact Phone #

Alternate Phone #

Social Security #

Email address

Race & Ethnicity (check all that apply)

Race & Ethnicity (check all that apply)

Are you a US Citizen?

Are you a US Citizen?

If work authorized, Registration #:

EMPLOYMENT/SCHOOL INFORMATION

Are you currently employed?

Are you currently employed?

If yes, who is your employer?

What is your job title?

Hourly Wage?

Date employment began (MM/DD/YYYY) and number of months or years in role:

Are you currently attending school? (Check all that apply)

Are you currently attending school? (Check all that apply)

Are you Full Time or Part Time?

Are you Full Time or Part Time?

Highest school grade completed (K-12)

Highest Educational Level Completed

Highest Educational Level Completed
A
B
C
D
E
F

ADDITIONAL INFORMATION

Are you a youth in the foster care system?

Are you a youth in the foster care system?
A
B

Are you a US Military Veteran?

Are you a US Military Veteran?
A
B

If available, do you need assistance with:

If available, do you need assistance with:

Photo/Video Release

Mineral Area College and/or the US Department of Labor may obtain and use my image and/or interview for publication. I understand my name may appear with my image or within a written article or video.

Mineral Area College and/or the US Department of Labor may obtain and use my image and/or interview for publication. I understand my name may appear with my image or within a written article or video.
A
B

Initials

Information Release

I authorize the MOSEP Works staff and instructors of Mineral Area College to share with the US Department of Labor, MOSEP Works consortium members, and my grant-related employer the following information:
• instructor notification memos, class progress, grades, program completion and certificates.
• discuss my academic progress and class attendance as they relate to credit and noncredit programs provided through the MOSEP Works grant.

I authorize the MOSEP Works staff and instructors of Mineral Area College to share with the US Department of Labor, MOSEP Works consortium members, and my grant-related employer the following information: • instructor notification memos, class progress, grades, program completion and certificates. • discuss my academic progress and class attendance as they relate to credit and noncredit programs provided through the MOSEP Works grant.
A
B

Initials

This Department of Labor grant has established justice-involved individuals as a population who might benefit from
grant programs and services. Have you ever been convicted of a criminal offense?

This Department of Labor grant has established justice-involved individuals as a population who might benefit from grant programs and services. Have you ever been convicted of a criminal offense?
A
B

I CERTIFY THAT THE INFORMATION GIVEN ON THIS APPLICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT SUCH INFORMATION IS SUBJECT TO VERIFICATION, AND I FURTHER REALIZE THAT FALSIFIED OR FRAUDULENT INFORMATION MAY RESULT IN THE REJECTION OF THIS APPLICATION, SUBSEQUENT TERMINATION FROM THE PROGRAM OR PROSECUTION UNDER THE LAW. WE ARE ASKING YOU TO PROVIDE VOLUNTARILY YOUR SOCIAL SECURITY NUMBER SO THAT THIS AGENCY CAN PROVIDE ASSISTANCE TO YOU IN THE MOST TIMELY AND EFFICIENT WAY. THIS INFORMATION WILL BE USED TO IDENTIFY YOUR RECORD IN FILING SYSTEMS, FOR FOLLOW-UP SERVICES PROVIDED YOU, FOR VERIFICATION OF ELIGIBILITY FOR SERVICES INCLUDING MONETARY, AND FOR STATISTICAL REPORTING PURPOSES.

Signature

Date

MoSEPWork Apprenticeship Participant Application This workforce product was funded by the MoSEPWork grant awarded by the U.S. Department of Labor’s Employment and Training Administration. The product was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. This product is copyrighted by the institution that created it.
Mineral Area College does not discriminate on the basis of race, color, national origin, gender identity, disability, age, religion, creed, sexual orientation, genetic and family medical history as defined by GINA, or marital or parental status, in admission/access to, or treatment/employment in its programs and activities. For further information about this policy, contact: Director of Human Resources, (573) 518-2378, 5270 Flat River Road, Park Hills, MO 63601. Inquiries also may be directed to the U.S. Department of Education, Office of Civil Rights at [email protected]
1 *The submission of your social security number is requested. The apprentice’s social security number will only be used to verify the apprentice’s periods of employment and wages for purposes of complying with the Office of Management and Budget related to common measures of the Federal job training and employment programs for measuring performance outcomes and for purposes of the Government Performance and Results Act. The Office of Apprenticeship will use wage records through the Wage Record Interchange System and needs the apprentice’s social security number to match this number against the employers’ wage records. Also, the apprentice’s social security number will be used, if appropriate, for purposes of the Davis Bacon Act of 1931, as amended, U.S. Code Title 40, Sections 276a to 276a-7, and Title 29 CFR 5, to verify and certify to the U.S. Department of Labor, Wage and Hour Division, that you are a registered apprentice to ensure that the employer is complying with the geographic prevailing wage of your occupational classification. Failure to disclose your social security number on this form will not affect your right to be registered as an apprentice. Civil and criminal provisions of the Privacy Act apply to any unlawful disclosure of your social security number, which is prohibited.
2 The College is committed to providing access and reasonable accommodations for individuals with disabilities. If you have accommodation needs, please contact the Access office at the campus where you are registering at least six weeks prior to the start of class to request accommodations. Event accommodation requests should be made with the event coordinator at least two working days prior to the event. Documentation of disability may be required.
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Please check one of the boxes below:

Please check one of the boxes below:

Your name:

Date

Why are you being asked to complete this form?

Because we are a sponsor of a registered apprenticeship program and participate in the National Registered Apprenticeship System that is regulated by the U.S. Department of Labor, we must reach out to, enroll, and provide equal opportunity in apprenticeship to qualified people with disabilities.[1] To help us learn how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for apprenticeship, any answer you give will be kept private and will not be used against you in any way.

If you already are an apprentice within our registered apprenticeship program, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our apprentices at the time of enrollment, and then remind them yearly, that they may update their information. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to: blindness, deafness, cancer, diabetes, epilepsy, autism, cerebral palsy, HIV/AIDS, schizophrenia, muscular dystrophy, bipolar disorder, major depression, multiple sclerosis (MS), missing limbs or partially missing limbs, post-traumatic stress disorder (PTSD), obsessive compulsive disorder, impairments requiring the use of a wheelchair, and intellectual disability (previously called mental retardation).

[1] Part 30 - Equal Employment Opportunity in Apprenticeship. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Apprenticeship website at https://www.apprenticeship.gov/eeo