The Harambee House / Citizens for Environmental Justice continues its twenty years of providing environmental and green technology training and the resources necessary to ensure that eligible members of the greater Savannah community can acquire skills relevant for the 21st and 22nd Centuries. This training provides information and awareness to the Savannah community of hazard containment and remediation, environmental clean-up, and ecological sustainability.

To apply and join our training class this year, please fill out and submit this form

Section 1: Personal Information

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Home Phone

Cell Phone

Work Phone

What is the best time to call?

• Morning 8am -- 12pm
• Afternoon 12pm -- 5pm
• Evening 5pm -- 7pm

Gender (optional) *

• Male
• Female

Ethnic Group (optional) *

• White
• African American/Black
• Caribbean-American
• Latino/Hispanic
• Indigenous/North American
• Asian/Asian American/Pacific Islander
• Other
• Prefer not to say

If you were referred, please tell us who referred you.

Section 2: Health Questions

This program trains workers who will be wearing respirators (face masks) and heavy, enclosed clothing (similar to “space suits” worn by astronauts). There are legal requirements that include NO BEARDS. Do you think this would pose a problem for you? *

• Yes
• No

Do you think you are able to wear a face mask? *

• Yes
• No

A space suit (enclosed clothing)? *

• Yes
• No

How do you rate your general health? *

• Excellent
• Good
• Fair
• Poor

Do you smoke? *

• Yes
• No

Do you have any health problems or disabilities? *

When did you last visit a doctor? *

What, if any, medications do you take? *

Have you been tested for COVID-19 *

• Yes
• No

Date of your first test *

Date of your second test (if applicable)

Date of your third test (if applicable)

What were the results of your last test? *

• Neg
• Pos

Have you been in contact recently with anyone you are aware of that tested positive for COVID-19? *

• Yes
• No

Have you received the COVID-19 vaccination? *

• Yes
• No

If Yes, which vaccine have you received? *

• Pfizer-BioNTech (2 shots required, 21 days apart)
• Moderna (2 shots required, 28 days apart)
• Johnson & Johnson’s Janssen (1 shot required)

Have you received: *

• 1st of 2 shots
• both shots
• only one shot required

Section 3: Conviction Record

Persons with criminal conviction records are still eligible for this training program. If you have a conviction record, we want to know so that the training can match any scheduling needs you may have.

Do you have a criminal conviction record? *

• Yes
• No

Please explain:

Section 4: Educational Background

Did you graduate high school? *

• Yes
• No

Highest grade completed?

Do you have a GED? *

• Yes
• No

If yes, when did you receive it?

Have you been in any other schools or training programs since high school?

• Yes
• No

If so, please list the name(s), address(es), type(s) of program(s), years attended, and reasons for leaving

Do you have any experience using special equipment?

• Yes
• No

Do you have any experience using professional tools?

• Yes
• No

Please explain:

Section 5: Employment Background

Please tell us about your work history, starting with your most recent employment

Current or most recent employer *

Supervisor

First

Last

Employer Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Job title and/or description

Wages per hour

Hours per week

Date employment started

Date employment ended

May we contact this employer

• Yes
• No

Previous employer

Supervisor

First

Last

Employer Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Job title and/or description

Wages per hour

Hours per week

Date employment started

Date employment ended

May we contact this employer

• Yes
• No

Section 6: Verification

By checking the checkbox below you affirm that the information given on this application is true to the best of your knowledge *

• The information I have given here is completely true

To the applicant:

You may be required to provide documentation for any of the information entered on this application. Some of the documents you will be asked for include: (1) Social Security Card (2) Identification (Photo ID) with proof of age

Date / Time

Date

Time

Message

Submit

An Harambee House representative will contact you soon!