COURSE SELECTION FORM Network Security TAACCCT INTERFACE Grant Fall 2014 Instructions: 1. Download application* and Course Selection Form to a USB drive or your personal computer 2. Fill out the grant application and Course Selection form on your computer 3. Print, then sign the grant application (TWO signatures required*) 4. Submit the SIGNED application and Course Selection Form using ONE of the following methods: Fax to 608-243-4754 (Dean s office School of Business and Applied Arts) Email to lflarsenmccarthy@madisoncollege.edu (OR) In person to: Madison College-Truax Campus School of Business and Applied Arts, Room D3631 1701 Wright Street, Madison WI 53704 (OR) In person to: Madison College-Cisco Networking Academy, Rm. 102, 1802 Wright Street, (Lana L. McCarthy) Madison, WI 53704 *Please note: If you have already applied to the grant and been accepted, you do not need to fill out the application form again. IN ORDER TO REGISTER FOR CLASSES, the COURSE SELECTION FORM MUST ALWAYS BE FILLED OUT. LAST NAME FIRST Student ID # Date: COHORT NS-B1: September 2 December 23, 2014 Network Security Specialist Course Selections (Grant Funded Tuition) Select course with X Course Number Title Days Times Start/End 10-107-111-0902 (35010) Exploration of IT Wed 9:30 AM 12:20 PM September 3 October 22 10-150-121-0902 (35013) Intro to Cisco Mon Wed 2:20 PM 4:20 PM September 3 December 23 10-154-184-0902 (35011) Windows Client Tuesday Thursday 8:30 AM 10:20 AM September 2 December 23 10-152-109-0902 (35012) Python Programming Tuesday Thursday 12:30 PM - 2:20 PM September 2 December 22 10-150-160-0902 (35009) IT Security Awareness Wed 9:30 AM- 12:20 PM October 29 December 17
Network Specialist - Fall 2014: Weekly Schedule Monday Tuesday Wednesday Thursday 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM Cisco Cisco 10:30 AM Networking 2 Networking 2 11:00 AM Windows Windows 11:30 AM Powershell 9:00 AM Powershell 9:00 AM 12:00 PM 12:20 PM 12:20 PM 12:30 PM 10:30-12:20 PM 10:30-12:20 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM Written Written 3:30 PM Communication Communication 4:00 PM 2:30 PM - 3:50 PM 2:30 PM - 3:50 PM 4:30 PM Page 2 of 6
Department of Labor TAACCCT GRANT (Trade Adjustment Assistance Community College and Career Training) PROGRAM ENROLLMENT FORM *PLEASE ENTER INFORMATION FIRST, THEN PRINT FOR SIGNATURES* Summer Fall Spring Year (Please check one) (Please fill in) IDENTIFICATION Last First, Middle Initial Date of Birth Address City State Zip County Social Security Number* Home Phone Cell Phone Email Address *Required PROGRAM Student ID#: Program Enrolled? Yes No Program Name: EDUCATION & TRAINING GED/High School Diploma/HSED Yes No High School attended: City : State Graduated (Month/Year) Post High School Institution: Post High School Years: Highest Grade Completed: Currently a student? Where are you attending? Have either of your parents completed a 4-year degree? Yes No EMPLOYMENT STATUS Currently Employed? Yes No In IT Related Field? Yes No If Employed: Current Employer Current Position Current Hourly Wage Average hours per week: <10 11-20 21-40 >40 Desire more hours per week: Yes No If not currently working, last position of employment: Average hours per week: <10 11-20 21-40 >40 Have you been laid off of work in the last 5 years? Yes No If yes, Company of Dislocation: (Select if applicable): Displaced Homemaker Single parent Economically disadvantaged WORK EXPERIENCE & TRAINING Do you have experience in an IT Related Field? Years of previous IT experience: Other (experience): Page 3 of 6
VETERAN STATUS Registered w/selective Service*(Required for all males age 18 and older): Yes No N/A Veteran: Yes No Eligible spouse of veteran or active service member: Yes No CITZENSHIP/INTERNATIONAL STATUS (select one) If a veteran, are the following documents on file with college: Report of Separation (Form DD-214) WI License ID with Veteran Identifier None U.S. CITIZEN Yes No *(U.S. citizenship is a requirement for enrollment in this grant program) LEGAL RESIDENCE WISCONSIN COUNTY: City Village Town of (Township) HIGH SCHOOL DISTRICT: (Name of High School District of your Legal Residence) OR MINNESOTA OR OTHER: (Name of State/Country) OTHER INFORMATION Madison College appreciates your cooperation in completing the following information, which is needed to meet State and Federal reporting requirements. These items remain confidential. Madison College and the Wisconsin Technical College System use the information for statistical reporting in efforts to better serve our educational community. (See below for help with definitions) MARITAL STATUS SINGLE MARRIED SEPARATED LEGALLY SEPARATED DIVORCED WIDOWED ETHNIC GROUP AMERICAN INDIAN/ALASKAN NATIVE ASIAN BLACK HISPANIC NATIVE HAWAIIAN/PACIFIC ISLANDER WHITE OTHER FAMILY STATUS: How many people in your household? STATISTICAL STATE DEFINITIONS DISPLACED HOMEMAKER A person who: Is not gainfully employed Has had or would have difficulty in securing employment Has been dependent on the income of another family member, but is no longer supported by such income; has been dependent on public assistance, but is no longer eligible for such assistance; or is supported as the parent of minor children who are within two years of reaching the age of majority; Has worked within the home for a number of years providing household service for family members, without pay ECONOMICALLY DISADVANTAGED A person who is receiving assistance from State or Federal Student Financial Aid programs or from assistance programs such as Aid to Families with Dependent Children, Energy Assistance, Food Stamps, Supplemental Security Income, General Assistance, JTPA, Indochinese Refugee Aid, or the Division of Vocational Rehabilitation SINGLE PARENT A person who is unmarried or legally separated from a spouse and is pregnant or has a minor child for whom the parent has either custody or joint custody WORK STATUS Not in Labor Market Unemployed Dislocated Worker Underemployed Without a job and not seeking work. Without a job and seeking work. Been laid off, terminated, or received notice of such; is eligible or has exhausted unemployment compensation entitlement; or is unlikely to return to previous occupation. Employed full or part-time, but the job duties are materially below your qualifications. All information is for statistical purposes as required by state and federal laws and is in compliance with the Family Educational Rights & Privacy Act of 1974 (Buckley Amendment) Page 4 of 6
DO YOU SPEAK ENGLISH AS YOUR SECOND LANGUAGE? Yes (If yes, what is your first language? No NEEDS: Are you a person with a disability? (includes learning disability) YES NO Describe your disability and/or special services you need because of it. INCOME ELIGIBILITY INFORMATION: (Select all that apply) Select any of the following that your family received with the last six months. Cash Public Assistance Pell Grant GA/SSI/RCA Food Stamps Energy Assistance TANF For the past six months, estimate the gross income for ALL family members (those related by blood, marriage or adoption) living in your household. Do not include the income of anyone who is considered independent for tax purposes. Do not include child support, foster child payments or unemployment compensation in your income. Estimated Family Household Income $ for the Past 6 Months BARRIERS TO EMPLOYMENT: (Select all that apply) Basic Skills Deficient (reading or math grade level below 9 th grade level) Pregnant or Parenting Foster Child Offender High School Dropout Single Parent Require additional assistance to secure and hold a job Runaway Homeless Been involved in the juvenile criminal justice system Been involved in the adult criminal justice system TAA/WIA Are you receiving any form of TAA assistance? Yes No Are you receiving WIA assistance? Yes No (Trade Adjustment Assistance) (Workforce Investment Act) How did you hear about this program? REQUEST FOR RELEASE OF ACADEMIC RECORDS INFORMATION I authorize the Department of Labor to obtain records pertaining to the course listed above including grades, attendance & tuition. This release is valid for three years from the date it is signed. A copy of this release is as valid as the original. SIGNATURE DATE / / This is to certify that this declaration is made for the purposes of my academic record and that I intend to use this name consistently for these purposes at Madison Area Technical College The U.S. Department of Labor s Employment and Training Administration has funded 100% of this project equaling $1,895.538. This is an equal opportunity employer/program which provides auxiliary aids and services upon request to individuals with disabilities by calling 711 or 800-947-6644 Voice/TTY. **DO NOT PRINT THIS FORM UNTIL AFTER YOU HAVE FILLED IN THE INFORMATION** Page 5 of 6 (Revised 4/22/14)
Participant Equal Opportunity Notice Wisconsin s 16 technical colleges were awarded a $23.1 million grant from the U.S. Department of Labor in 2013 with the goal of assisting TAA-eligible workers, veterans, and other adults in obtaining education and joining the workforce, and to build a pipeline of workers in IT-related career fields. The classes/program you are involved with have been touched by this grant. As a result, we need to obtain your acknowledgement of receipt of the following disclaimers to meet grant requirements. Questions may be directed to Madison College s Information Technology TAACCCT 3 INTERFACE contact person - Lana L. McCarthy by email at lflarsenmccarthy@madisoncollege or by calling 608-246-6207. Disclaimers: 1. This program is as an equal opportunity program. EQUAL OPPORTUNITY IS THE LAW 29 CFR SUBTITLE A (7-1-13 EDITION) It is against the law for Madison College, a recipient of federal financial assistance, to discriminate on the following basis: against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA), on the basis of the beneficiary s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following areas: deciding who will be admitted, or have access, to any WIA Title I-financially assisted program or activity; providing opportunities in, or treating any person with regard to, such a program or activity; or making employment decisions in the administration of, or in connection with, such a program or activity. WHAT TO DO IF YOU BELIEVE YOU HAVE EXPERIENCED DISCRIMINATION Equal Opportunity No person may be denied admission to, participation in, employment at, the benefits of, or be discriminated against in any service, program, course, or facility of the Madison College District because of the person's political affiliation, age, race, creed, religion, color, handicap (disability), marital status, parental status, sex, national origin, ancestry, sexual orientation, pregnancy, arrest record, conviction record, service in the armed forces, genetic testing, or use or non-use of lawful products off the District premises during non-working or non-class hours. Madison College Equal Opportunity Education and Employment Policy: Malika Evanco at 608-243-4449. Madison College Equal Opportunity Affirmative Action Annual Report: Malika Evanco at 608-243-4449. The following persons have been designated to handle inquiries regarding Madison College s nondiscrimination polices: Affirmative Action/EEO Officer Malika Evanco 1701 Wright Street Madison, WI 53704 608-243-4449 Title IX Coordinator Keith Cornille 608-246-6464 ADA/504 Coordinator Kristin Gebhardt 608-246-6902 General demographic and job placement information of program participants will be used and reported to the U.S. Department of Labor as one measurement of success for this grant funded program. I acknowledge receipt of the equal opportunity and use of demographic and job placement information disclaimers. Signature Date **DO NOT PRINT THIS FORM UNTIL AFTER YOU HAVE FILLED IN THE INFORMATION** Page 6 of 6