Green Infrastructure Training

First Name*

Last Name*

Address: Street*

Address: City*

Address: State*

Address: Zip Code*

Mobile Phone*

Home Phone

Work Phone

Email*

Race*American Indian or Alaskan NativeAsianBlack or African AmericanCaucasianMulti-RacialNative Hawaiian or Pacific IslanderOther

Ethnicity*HispanicNon-HispanicOther

Gender*FemaleMaleTransgenderOther

Birthdate*

Level of Education* Less Than High School GraduateHigh School Diploma / GED2 – Year CollegeBachelor’s DegreeGraduate School / Post – Secondary

Languages Spoken* Cape VerdeanEnglishFrenchGreekHaitian CreolePortugueseSpanish

How many people (including yourself) currently live in your home?
(If just you, enter the number 1).*

Annual Household Income Range* $20,000 and below$20,001 to $30,000$30,001 to $40,000$40,001 to $50,000$50,001 to $60,000$60,001 to $70,000$70,001 to $80,000$80,001 to $90,000$90,001 to $100,000$100,001+

If working: What kind of work are you doing?*

If you are not working: What was the last type of work you did?*

Do you want to make green infrastructure a career?* YesNo

Are you just exploring the field of green infrastructure at this time?* YesNo

What makes you interested in taking this training in green infrastructure?*

After you complete the 35 hour green infrastructure class, do you intend to take the certification exam?* YesNo

What type of green infrastructure career would you like to pursue?* Green roof installation, maintenance, and inspectionWorking for a municipal water and sewer agencyWorking for a municipal public works agencyWorking for a municipal parks agencyWorking in the construction tradesTree planting and maintenanceRain garden, bioswale, installation, maintenance and inspectionOther

If selected Other, please specify:

Are you comfortable working outdoors under the sun and in the rain?* YesNo

Are you comfortable working in high places (ie, on a roof, etc.) with safety equipment?* YesNo

Referrals

Please provide contact information for up to two (2) people you believe we should reach out to who also may be interested in Green Infrastructure Training.

Referral Name 1

Referral Email 1

Referral Phone 1

Referral Name 2

Referral Email 2

Referral Phone 2