Register Your Apprentice - DC Students Construction Trades

DC APPRENTICESHIP ACADEMY
NEW APPRENTICE REGISTRATION FORM: 2016-17
TRADES – CLASSROOM AND LAB:
Carpentry
Concrete Form Building
Electrical
Reinforced Ironworker
TRADES – SELF-PACED STUDY WITH CLASSROOM
TESTS – NO LAB ACTIVITIES:
Operating Engineer (Heavy Equipment)
Other trade requested:________________________
Entering Level:
Entering Level:
1
2
3
4
1
Completed Core Curriculum
Yes
No
*If applicable, attach copies of any NCCER credentials and
transcripts from training completed at other schools.
2
3
4
*Staff will contact your employer to discuss any other trade requested.
STUDENT INFORMATION: Please print clearly or type information.
First Name
Middle Name
Last Name
Mailing Address
City, State
Zip
Cell Phone
Home Phone
*preferred
Receive text messages
Yes
*preferred
Email Address
*preferred
No
Date of Birth
Social Security Number
__ __ /__ __ /__ __ __ __
MO DAY YEAR
__ __ __ - __ __ - __ __ __ __
Gender
Male
Female
NCCER Card Number
______________________________
School you attended last year:
n/a
DC Apprenticeship Academy
Date you were registered with the DC Apprenticeship Council:
Attach copy of Apprenticeship Agreement, driver’s license, Social Security card, and any NCCER credentials and transcripts
earned at another school prior to attending DC Apprenticeship Academy.
Other (specify) ________________
_______________________________
In Case of Emergency Contact:
Current Employer:
Name:
Supervisor’s Name:
Phone #:
Phone #:
Relationship:
2016-17 Page 1 of 2
DC Apprenticeship Academy New Apprenticeship Registration Form 2016-17
NCCER REGISTRATION AND RELEASE FORM
I hereby authorize the NCCER registry department to verify information in my training records to Sponsor Representative/ Primary
Administrator upon request. I release and hold harmless NCCER for this verification process.
I, the undersigned, do hereby authorize the DC Students Construction Trades Foundation to release the information and results
attained through the administering of the NCCER Registry System to the company referenced above, and acknowledge that said
company is my present employer.
I do hereby release the DC Students Construction Trades Foundation, its representatives, and its associating entities from any and
all liability that may result from the release of this information. I further agree to hold harmless DC Students Construction Trades
Foundation, its representatives and associating entities from any and all damages for liability therefore which may result from the
release of said information.
Initial_______
STATEMENT OF UNDERSTANDING
I acknowledge and accept that all materials and tools are the property of the DC Apprenticeship Academy and these materials are
not transferable or to be shared with other entities. I understand and agree that the DC Apprenticeship Academy and the DC
Students Construction Trades Foundation may photograph, videotape or otherwise record my training sessions for educational or
promotional use. I authorize and hereby give my permission for the DC Apprenticeship Academy to record, in any manner, at any
time, my training sessions and myself. I also understand that copies of my training sessions may be made available for purchase with
the proceeds going to the Foundation.
Initial_______
WAIVER OF LIABILITY
In consideration of the opportunity afforded to me to be provided with training at the DC Apprenticeship Academy, at IDEA
Public Charter School, in the District of Columbia, or any associated training locations, I hereby waive and release any claim, right,
demand, or cause of action arising out of or related to my participation as a student of the DC Apprenticeship Academy from which
any liability may or could accrue against the DC Apprenticeship Academy, the District of Columbia Students Construction Trades
Foundation, Inc., IDEA Public Charter School, and their officers, directors, trustees, employees and consultants collectively or
individually. Without limiting the foregoing, I agree that this waiver of liability shall include any claims, rights, demands and causes of
action resulting from personal injury to me or damage to my property sustained in connection with my activities as a student at the
DC Apprenticeship Academy.
Initial_______
________________________________________________________
Signature
________________________________________________________
Print Name
_______/______/_______
Date