RETAIN Application

Legal First and Last Name *

Preferred Name *

Date Of Birth *

Cell Phone Number *

Home Address *

Personal Email Address *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Work Email Address *

Employer Name *

Employer Address *

Employer Type (for profit, non-profit, government, etc...)

Supervisor Name and Title *

Your Current Position/Job Title *

Current Salary (Salary only, not including benefits or bonus) *

Is your employer a minority or women owned business?

Highest Level of Education Completed? *

Most recent education completed. Including school, program and/or certification name *

When did you graduate from your most recent educational program? (2-year, 4-year, trade school) *

Please tell us about any volunteer or community service experiences that have been rewarding to you

Are there local organizations, causes, or initiatives you currently support *

yes

no

If yes, share how you prioritize community engagement with your personal and professional life

Are you interested in joining any professional associations, networking groups, or community orgs?

yes

no

How long do you plan to stay in Rochester *

Where did you live before school, if not in the Greater Rochester region?

How did you hear about RETAIN *

What specific skills or competencies do you hope to develop through participating in RETAIN? *

Gender Identity

Male

Female

Non-Binary

Other/Prefer Not to Answer

Preferred Pronouns: She/Her/Hers, He/Him/His, They/Them/Their, other

She/Her/Hers

He/Him/His

They/Them/Their

Other/Prefer Not to Answer

Which of the following race/ethnicities do you identify with? Check all that apply

American Indian or Alaska Native

Asian

Black or Afriacn American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Other/Prefer Not to Answer

Are you a Veteran

Yes

No

Will you require any accessibility accomidations for full participation in the RETAIN sessions?

Yes

No