kalamazoo Valley Community College

Full Name: *

First Name

Last Name

Please indicate your ethnicity: *

Hispanic

African American

Native American

Asian

White

Other

Date of Birth: *

MM

DD

YYYY

Gender:

Options: Male, Female, Non-Binary, Prefer not to say, Other (please specify)

Male

Female

Non-binary

Prefer Not to Say

Other

Please indicate your preferred pronouns:

He/Him/His

She/Her/Hers

They/Them/Theirs

Other

Please select your current age range below: *

21 - 35 years old

35 -50 years old

50 - 60 years old

60 - 100 years old

Are you a current resident of the City of Kalamazoo? *

(You must be able to verify your address via bill mail addressed to applicant, passport, driver’s license, car insurance, letter or affidavit of residency if staying in a shelter or other facility)

Yes

No

Do you have any prior experience in the cannabis industry? *

Yes

No

Employment Status: *

Are you currently employed?

Yes, I am currently employed

No, I am not currently employed

Annual Household Income: *

What is your annual household income? Please select the appropriate range below

Less than $25,000

$25,000-$50,000

$50,000-$75,000

Above $75,000

Other

Up-front Fee Acknowledgement: *

I understand that I will be responsible to pay the cost of the program (approx. $750-850) upfront, and that this cost will be reimbursed to me after completion of the program.

I understand

Initial Financial Aid Request: *

Please indicate below if you would like more information on financial aid options to cover the initial costs of the program.

Yes

No

Which cannabis workforce program do you intend to complete? *

Cannabis Extraction

Cannabis Cultivation

Cannabis Retail

Phone *

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