Name and Contact Information

First Name

Legal First Name

Last Name

Date of Birth

MM/DD/YYYY

Cell Phone Number

May we send you text messages?

YesNo

Street Address

City

State

Country

Zip/Postal Code

Do you have an Illinois valid driver's license?

YesNo

I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud. I understand that this information will be kept confidential and will not be released to the public. I have been advised that this information will be entered into a computerized information system and may be shared with other authorized agencies for the purpose of administering programs of these agencies. I understand that I have the right to inspect this information and initiate appropriate corrections through the agency to which I am providing this information.

Female	Male
Nonbinary/third gender	Prefer not to say
Other

American Indian or Alaskan Native	Asian
Black/African American	Native Hawaiian or Other Pacific Islander
White	Choose not to respond
Hispanic/Latino

American Indian or Alaskan Native	Asian
Black/African American	Native Hawaiian or Other Pacific Islander
White	Choose not to respond
Hispanic/Latino

Single	Married
Divorced	Widowed
Separated	Choose not to respond

Bachelor’s Degree or Higher	Associate's Degree
Certificate	Some College
High School Diploma	GED
None	Other

CNA only	Medical Coder
Dental Hygienist	Medical Lab Technician
Physical Therapist Asst.	Nursing
Radiographer	Medical Assistant
Occupational Therapy Asst.	Surgical Technologist
Medical Office Admin Asst.	Paramedic
Other

Full Time	Part Time
Unemployed	Seasonal
Temporary	Retired