The Well CDC Akron -

Career Development Application Form

Thank you for your interest in our career development program. Please fill out the form below to apply and get started. If you have any questions, please email Tanisha Lash: tanisha@thewellakron.com

First Name *

Last Name *

Preferred Pronouns? *

Social Security Number *

Date of Birth *

Preferred Method of Contact

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Email *

Phone *

Gender *

Ethnicity/Race *

Primary Language? *

Highest level of education *

What are you looking for in a job/career? *

Are you willing to commit to our 5 week program, Tuesday through Friday from 10AM-2PM, to help you establish the next steps in your career search?

Yes

No

Is childcare a major barrier for you? *

Yes

No

Is transportation a major barrier for you? *

Yes

No

How did you hear about The Well CDC Career Development Program? *

Have you ever been convicted of a misdemeanor or felony (this does not disqualify you)? If yes, please explain. *

Please type your full name and today's date below for authorization.