Workforce Application

Center for Workforce & Professional Education
University of Central Missouri
Lee's Summit, MO 64086
660.543.6198

Student Information

Legal First Name

Middle Name

Legal Last Name

Suffix

Preferred Name

Birthdate

Gender

Social Security Number

SSN Agreement

I understand that my social security number may be provided to the state of Missouri to satisfy wage reporting for federal WIOA (Workforce Investment and Opportunity Act) compliance if I am enrolled in a WIOA-eligible program.

Contact Information

Phone Number

Phone Type

Email Address

Permanent Address

Country

Street

City

Region

Postal Code

Alternate Address

I have preferred mailing address that is not my permanent address.

Mailing Address

Country

Street

City

Region

Postal Code

Program Information

Intended Program Category

Preferred Start Date

Tuition Assistance/Scholarship Information

Are you receiving a scholarship for your course?

Scholarship Provider

Counselor or Scholar Advocate Name

Additional Information

Relationship Type = Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Are you of Hispanic, Latino, or Spanish origin?

Disability

Limited English Proficient

Preferred Language

Are you a current or veteran member of the U.S. Armed Forces, or a dependent of one?

What is your military affiliation?

Which military branch?

Policies

Refunds: Full refunds are available up to five (5) working days prior to the program. After that, no refunds are available without extenuating circumstances, but registrations are transferrable to other individuals.

Cancellations: To drop or withdraw from this class you must contact Workforce Development.

Non-Discrimination: It is the policy of University of Central Missouri to provide equal opportunity to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, we will provide reasonable accommodations for qualified individuals with disabilities.

Student Signature

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