CRY-ROP
1214 Indiana Court, Redlands, CA 92374
Adult Programs Application
How will the program be funded?
...
American Job Centers of CA (AJCC)-SB
Cash/Payment Plan
Department of Rehab
Equus
Other
Transitional Assistant Department (TAD)
No Tuition (HIGH SCHOOL STUDENTS ONLY)
Center for Employment Opportunities (CEO)
American Job Centers of CA (AJCC)-Riverside
First Name
Middle Name
Last Name
Gender
...
Male
Female
Non-Binary
Birth Date
Social Security No
Street
City
State/Province
...
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces
Armed Forces Americas
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
N/A
Zip/Postcode
Mailing Address (if different from street address)
City
Zip Code
Home Phone
Cell Phone
Email
Ethnicity: Are you hispanic or Latino?
Yes
No
Not Selected
Race: Indicate what you consider your race to be
AFRICAN AMERICAN
ALASKAN NATIVE
AMERICAN INDIAN
ASIAN
FILIPINO
OTHER
PACIFIC ISLANDER
WHITE
HISPANIC
Please check up to 5 categories
Scrub Size-Top
...
XS
S
M
L
XL
2XL
3XL
Scrub Size-Bottom
...
XS
S
M
L
XL
2XL
3XL
Initial Interview Questions
Do you have a computer or chromebook?
Yes
No
Not Selected
Do you have internet access?
Yes
No
Not Selected
Have you been CONVICTED, at any time, of any crime, other than a minor traffic violation? (You need not disclose any marijuana-related offenses specified in the marijuana reform legislation and codified at the Health and Safety Code, Sections 11361.5 and 11361.7).
Yes
No
Not Selected
If yes, list conviction:
Court of conviction:
Date:
Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc.) against you?
Yes
No
Not Selected
If yes, indicate the type and number of license/certificate:
Education
Please answer yes or no for each option below.
High School Diploma/Equivalency
Yes
No
Not Selected
Advertisement-How did you hear about us
Yes
No
Not Selected
Brochure-How did you hear about us
Yes
No
Not Selected
Career Center-How did you hear about us
Yes
No
Not Selected
Counselor-How did you hear about us
Yes
No
Not Selected
Friend/Relative-How did you hear about us
Yes
No
Not Selected
Instructor-How did you hear about us
Yes
No
Not Selected
Previously Enroll.-How did you hear about us
Yes
No
Not Selected
Other-How did you hear about us
Yes
No
Not Selected
Emergency Contact Information
Emergency Contact's Name
Cell Phone
Alternate Phone Number
Emergency Contact's Email
Relationship to Student
Parent/Guardian
Spouse
Friend/Relative
Other
Do you have a Health Insurance Provider?
Yes
No
Not Selected
Insurance Provider
Healthcare facility you prefer to be treated at:
Do you give permission for medical treatment in the event of an emergency?
Yes
No
Not Selected
Health/Disability Information
(select all that apply)
Diabetes
Yes
No
Not Selected
Epilepsy
Yes
No
Not Selected
Heart Condition
Yes
No
Not Selected
Pregnancy
Yes
No
Not Selected
Respiratory Conditions
Yes
No
Not Selected
Seizures
Yes
No
Not Selected
Other Health
Yes
No
Not Selected
If Other, please specify
Autism
Yes
No
Not Selected
Basic Skills Deficiency
Yes
No
Not Selected
Blind
Yes
No
Not Selected
Deaf
Yes
No
Not Selected
Developmental
Yes
No
Not Selected
Emotional
Yes
No
Not Selected
Hearing Impaired
Yes
No
Not Selected
Learning Disability
Yes
No
Not Selected
Mental Disability
Yes
No
Not Selected
Multiple Disabilities
Yes
No
Not Selected
Orthopedic Disability
Yes
No
Not Selected
Other Disability
Yes
No
Not Selected
Speech Impaired
Yes
No
Not Selected
Traumatic Brain Injury
Yes
No
Not Selected
Visually Impaired
Yes
No
Not Selected
Please describe any limitations you have that are related to your disability.
Please give details of allergies, etc.
Please describe any accommodation(s) being requested.
This does not mean all accommodations will be approved. Accommodations will be based on the disability and documentation provided.
Economic Information
(select all that apply)
Marital Status
...
Single
Married
Divorced
Seperated
Widow
Annual Income
...
$17,667 or less
$17,668 - $23,802
$23,803 - $29,938
$29,939 - $36,074
$36,075 - $42,210
$42,211 - $48,346
$48,347 - $54,482
$54,483 - $60,618
$60,619 or more
None Apply
Family Size
Financial Dependents
Academically Disadvantaged
Yes
No
Not Selected
Bureau of Indian Affairs Assistance
Yes
No
Not Selected
CalFresh or Medi-Cal
Yes
No
Not Selected
CalWorks Recipient or TANF
Yes
No
Not Selected
CalWorks Eligible
Yes
No
Not Selected
Dept. of Rehabilitation
Yes
No
Not Selected
Displaced Homemaker
Yes
No
Not Selected
Displaced Worker
Yes
No
Not Selected
Economically Disadvantaged
Yes
No
Not Selected
English 2nd Language (LEP)
Yes
No
Not Selected
Foster Care
Yes
No
Not Selected
General Assistance
Yes
No
Not Selected
Housing Support Program
Yes
No
Not Selected
Migrant/Non-Resident Alien
Yes
No
Not Selected
Other Qualifying Assistance
Yes
No
Not Selected
Single Head of Household/Single Parent
Yes
No
Not Selected
Single Pregnant Woman
Yes
No
Not Selected
Unemployment
Yes
No
Not Selected
WIA or WIOA -GenGo/AJCC
Yes
No
Not Selected
Workability
Yes
No
Not Selected
Enter the above code
Required
