ATTAIN Learning System

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If you work, study or reside in New York State, completion of this application will provide you access to ATTAIN resources.

This information is necessary in order to sustain ATTAIN services at no cost. We take our responsibility to protect the security of your information very seriously. We use physical, technical, and procedural safeguards that comply with applicable legal standards to secure your information from unauthorized access and use, alteration, and destruction.

An ATTAIN Lab Staff member will contact you upon submission of your completed application below. ¿Desea inscribirse en Español?

General

ATTAIN Lab

Trenton and Pamela Jackson R Center ATTAIN Lab

First Name

Last Name

Email Address

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Phone

Preferred Type of Communication

Text Email Call OK to leave a message

Primary Language

Please elaborate

Gender

Female Male X Other Prefer not to disclose Fill in gender identity

Select One or More Races/Ethnicity

Income ($X,XXX)

Combined Household Income:

Family Household:

Please enter family household information below.
If you are a non-custodial parent, please include your child(s) information below even if they do not live with you full-time.
If you do not live with someone, please mark N/A.

N/A

Name	Date of Birth	Relationship to you

Please indicate if you receive any of the following assistance:

SafetyNet
Temporary Assistance for Needy Families (TANF)
SNAP (Formerly Food Stamps)
Medicaid
SSI
HEAP
N/A or Non-Public Assistance

Highest Education Level Completed

Labor Force Status at Enrollment

Social Security number

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No SSN

Reason for No SSN

Date of Birth

How did you hear about ATTAIN?

Please elaborate

Do you have access to a computer/laptop outside of the lab?

Yes No

Do you have access to internet service outside of the lab?

Yes No

Demographic

Address

City/Town

State

New York

Zip Code

County of Residence

Veteran

Yes No

Limited English Proficiency

Education Data

Industry Recognized Certification

Participant Goals

Check all that apply

Academic Training: High School Equivalency, College Preparation
Occupational Training
Digital Literacy
Microsoft and QuickBooks Certifications
English as a Second Language (ESL) Training, Language Learning
Employability Training: Resume Building, Interviewing Skills, Social Media Professionalism
Other

SUNY ATTAIN is a Federal and State funded project providing technology and workforce development training to New York State Residents.

By checking, I am swearing that:

All of the above statements are true to the best of my knowledge and that I am willing to cooperate with any efforts to verify the information provided, including household composition and income.

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