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Please fill out the following application and email to [email protected]
The application is editable and you can type in your information.
You can also print the application, write in your answers and email back to us or turn it in at one of our 4 locations listed below.
Campus Information
Titusville – 321-264-3088 1311 US-1 Bld. #6 Titusville, FL 32796
Melbourne – 321-952-5977 1362 S. Babcock St. Melbourne, FL 32901
Palm Bay – 321-952-5914 101 Pirate Ln. Melbourne, FL 32901
Cocoa - 321-633-3660 1225 Clearlake Rd. Cocoa, FL 32922
Brevard Adult Education
Pre-Apprenticeship Application
Applicant Information
Full Name: Date of Birth:
Last First M.I.
Address: Street Address Apartment/Unit #
City State ZIP Code
Phone: Email
Gender Race or Ethnicity
Male American Indian/Alaskan Native Filipino
Female Asian or Pacific Islander Hispanic
Unstated Black/African American White (not of Hispanic origin)
Are you a citizen of the United States? YES
NO
If no, are you authorized to work in the U.S.? YES
NO
Previously or currently subject to any stage of the criminal process YES
NO
Emergency Contact
Full Name: Phone
Number Last First M.I.
Military Service
Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:
Education
High School: Address:
From: To: Did you graduate? YES
NO
If no, highest grade level
completed:
College: Address:
From: To: Did you graduate? YES
NO
Degree:
Vocation or Trade School: Address:
From: To: Did you graduate? YES
NO
Certification:
Brevard Adult Education
Pre-Apprenticeship Application
Employment
Are you currently employed? YES
NO
Would you like to be referred to career services? YES
NO
Please list your most recent 3 jobs
Company: Phone:
Address: Supervisor:
Job Title:
Responsibilities:
From: To: Reason for Leaving:
Company: Phone:
Address: Supervisor:
Job Title:
Responsibilities:
From: To: Reason for Leaving:
Company: Phone:
Address: Supervisor:
Job Title:
Responsibilities:
From: To: Reason for Leaving:
Construction Industry Interest In a brief statement state the reason(s) you are interested in the skilled trades industry and state your career goals
and plans after completing the pre-apprentice program.
Brevard Adult Education
Pre-Apprenticeship Application
Disclaimers and Signature
Initial: I agree to participate in student surveys Initial:_____ I authorize Brevard Adult Education to release my information to those involved in the section process,
Career Source Brevard, and the pre-apprentice committee. Initial:_____ I agree to allow my picture to be taken and possibly be used in either promotional material and/or
social media Initial:_____ I certify that I have read the rules and regulations for the Brevard Adult Education and pre-apprentice
program
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to enrollment, I understand that false or misleading information in my application or interview may result in my release.
Signature: Date:
Training Services Interest Form rev r c i re re ices i r r
The following information will help CareerSource Brevard staff determine which training services may be available to
you, as well as ensure you are directed to the appropriate staff member for assistance. Please take a few minutes to
answer the following basic eligibility questions.
First Name: ___________________________________ Last Name: _______________________________________
Last 4 of SSN: __________________________________ Email: ___________________________________________
Phone Number: ________________________________ Cell Phone: _______________________________________
Residential Address: _____________________________________________________________________________
How did you hear about CareerSource Brevard Training Opportunities?
CareerSource Brevard Staff
Flyer/Poster
CareerSourceBrevard.com website
Social Media (Facebook, Twitter)
School or Training Provider
Community Organization
Friend or Family
Other_______________________________
Are you currently registered in Employ Florida - https://www.employflorida.com/ ? Yes No
Are you currently employed? Yes No
Which Career Center is closest to your home? Rockledge itusville Palm Bay
i r r nti i r gra i r i in r ati n r gar ing t ing r i n a in i at i r i n i t int r t t
ating ir n iti ning n ta r r i
tri ian
i itt r
r
t ta r r
in r t r in an
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Yes NoAre you authorized to work in the United States?
r n r ar 1
Yes No
If Y to question #7, please answer the following questions:
Are you currently attending any school? (High school or post-secondary school)
If no, when did you last attend school? Month ________ and Year ________
How old are you? _________
Which best describes your current living situation
Lives with at least one parent or legal guardian
Lives with other relative(s)
Lives alone or with non-relative
Select all that apply to you:
Homeless Foster Child
Ex-Offender Have a disability
English Language Learner
Pregnant or Parenting
High School Dropout Attending Adult Ed/GED classes
In high school and qualifies for Free or Reduced Lunch
Family has received Public Assistance within the last 6 months
None of the above
If N to question #7, please answer the following questions:
Select all that apply to you:
I am separated from a job and receiving Reemployment Compensation, or have exhausted benefits
I have received Public Assistance within the last 6 months
I am the spouse of an active duty service member
I am a recently separated military veteran
I am a displaced homemaker – I provided unpaid services in the home but must return to work
I was formerly self-employed but am now unemployed due to economic conditions in the community
I am currently employed, but earning less than $20 an hour
None of the above apply to me
Family income information - Family is defined as you, your spouse, and dependent children living in the household:
Number of people in your household _______________
Total yearly gross income (before taxes) of household ______________
r c e i is r reerS rce rev r s e er i c ec i
2
Employment Opportunities: Students interested in the following career pathways will benefit from completing the course.
x HVAC x Electrical x Plumbing x Pipefitting x Sheet Metal x Line Erector x Manufacturing x Construction
Industry Certifications:
x OSHA 10-Hour General Industry Wallet Card
x NCCER Core Curriculum x Certified Production Technician x First Aid/CPR
Brevard Adult Education Offices:
1311 US-1 Building #6 Titusville, FL 32796 321-264-3088 1225 Clearlake Rd Cocoa, FL 32922 321-633-3660 1362 S. Babcock St. Melbourne, FL 32901 321-952-5977 101 Pirate Lane Melbourne, FL 32901 321-952-5914
Publication Date: 4/16/19
Mission Statement: Our goal is to serve every student with excellence as the standard. We strive to provide students with access to programs that are high quality, affordable, and enjoyable. Program Description: This program is designed to prepare participants to become an apprentice and to have an opportunity for career exploration in the trades. Program Structure: The Pre-Apprenticeship program will consists of the following:
x The National Center for Construction Education and Research (NCCER) Core Curriculum:
o Basic Safety o Introduction to Construction Math o Introduction to Hand Tools o Introduction to Power Tools o Introduction to Construction Drawings o Basic Communication Skills o Basic Employability Skills o Introduction to Material Handling
x OSHA 10 x First Aid/CPR x Certified Production Technician (CPT)
o Manufacturing Safety Awareness o Production and Processes o Maintenance Awareness
Quality Assurance x Opportunity for Work Experience provided through CareerSource Brevard. x Opportunity to Connect with a CareerSource Brevard Career Counselor.
Minimum Program Requirements:
o Must be at least 16 years of age. (A minor must have written parental or guardian consent to participate in the program)
o Physically capable of performing the work of the trade
Application Submission Requirements: Must submit application by April 22, 2019 via email to [email protected] or drop off to one of our four locations or mail to Brevard Adult Education, 1225 Clearlake Rd., Cocoa, FL 32922.
x Must complete CareerSource Brevard training service interest form for work experience opportunity.
x All applications will be reviewed by the advisory designee and committee in accordance with criteria, terms and conditions of the program.
Schedule: May 7, 2019 to November 19, 2019 Classes will be held on Tuesdays and Thursdays from 5:30 PM to 8:30 PM. Location: Brevard Adult Education, 1225 Clearlake Rd., Cocoa, FL 32922
FREE Pre-Apprenticeship
Program
