Intake Form - WeldCore

Section 1: Personal Information

Full Legal Name *

Date of Birth *

Social Security Number (SSN) *

Gender *

Male Female Prefer Not to Say

Address (Street, City, State, ZIP) *

Primary Phone *

Alternate Phone

Email Address *

Citizenship Status *

If Other, specify visa/status

Section 2: Demographic Information

Section 3: Emergency Contact

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Emergency Contact Alternate Phone

Section 4: Education & Background

Highest Level of Education Completed *

Name of Last School Attended

Year Graduated/Left

Any Previous Vocational/Trade Training? *

Yes No

If yes, describe

Section 5: Welding Experience & Interests

Have you welded before? *

Yes No

Years of Experience

Current Certifications (e.g., AWS)

Course

Desired Start Date (Month/Year)

How did you hear about us?

Section 6: Health & Safety Information

Do you have any medical conditions that could affect welding? *

Yes No

If yes, please explain

Any allergies (e.g., to metals, fumes, gloves)? *

Yes No

If yes, please explain

Vision: Do you wear glasses/contacts? *

Yes No

Hearing: Any issues? *

Yes No

Do you have a pacemaker or metal implants? *

Yes No

I understand welding involves hazards (UV light, fumes, sparks, heat). I agree to follow safety protocols. *

Section 7: Agreements & Consent

I certify the information above is accurate. *

I consent to WeldCore using my photo/video for promotional purposes. *

Yes No

I acknowledge receipt of the student handbook/safety policies. *

Signature *

Section 8: Payment/Registration

Course Fee Payment *

10% Deposit Paid in Full

Student Intake Form

Section 1: Personal Information

Section 2: Demographic Information

Section 3: Emergency Contact

Section 4: Education & Background

Section 5: Welding Experience & Interests

Section 6: Health & Safety Information

Section 7: Agreements & Consent

Section 8: Payment/Registration

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