Unlock Your Potential with Memphis Urban League NextUp Career Readiness Program Participant Registration Form Thank you for your interest in the Memphis Urban League NextUp Career Readiness Program.The Memphis Urban League is committed to empowering individuals and strengthening our community through workforce and economic development. NextUp is a 6-week program designed to equip participants with the skills, tools, and support needed to secure employment, advance their careers, and achieve economic stability. Through interactive workshops, career coaching, and employer connections, participants gain practical strategies for success in today’s workforce. Please complete this form so we can assess your eligibility, understand your career goals, and connect you to the training, resources, and opportunities that best support your success. SECTION 1: BASIC INFORMATION Full Name(First & Last) Date of Birth Age GenderMaleFemaleNon-binaryPrefer not to answer Phone Number Email Address Street Address City State/Province ZIP / Postal Code SECTION 2: ELIGIBILITY & BACKGROUND Are you currently employed?Yes (Full-time)Yes (Part-time)No If employed, what is your current job title? What is your current total annual household income?(Please select the range that best represents your total income before taxes.)No incomeLess than $10,000$10,000 – $19,999$20,000 – $29,999$30,000 – $39,999$40,000 – $49,999$50,000 – $59,999$60,000 – $74,999$75,000 + Highest level of education completedNo high school diplomaHigh school diploma / GED/ HiSetSome collegeAssociate degreeBachelor’s degreeGraduate degreeTrade/technical certification Are you currently enrolled in school or training?YesNo SECTION 3: TARGET POPULATION INDICATORS Do any of the following apply to you?(Check all that apply)UnemployedUnderemployedRecently laid offJustice-involved / justice-impactedVeteranPerson with a disabilitySingle parentReceiving public benefits (SNAP, TANF, etc.)None of the above SECTION 4: CAREER INTEREST & GOALS Which career field(s) are you most interested in?(Select up to 3)Business / AdministrationHealthcareConstruction / Skilled TradesTransportation / LogisticsTechnology / ITCustomer Service / RetailHospitalityEntrepreneurshipOther What type of job are you currently seeking?Full-timePart-timeTemporaryNot sure yet SECTION 8: PROGRAM COMMITMENT NextUp is a 6-week career readiness program that requires consistent participation and active engagement to maximize your success. While the program provides training, resources, and support, employment is not guaranteed. Are you able and willing to commit to attending regularly?YesNo Preferred ScheduleMorningAfternoonEveningWeekend (Saturday) How did you hear about this program?Memphis Urban LeagueSocial MediaFriend/FamilyCommunity PartnerEmployerOther SECTION 9: CONSENT & AGREEMENT Participant Agreement & Consent By submitting this form, I certify that the information provided is true and accurate to the best of my knowledge. I understand that providing false or misleading information may affect my eligibility for program services. I agree to:✔ Actively participate in program activities and workshops✔ Conduct myself in a respectful and professional manner✔ Work toward my employment and/or training goals I understand that Memphis Urban League will collect and use my information for program management, reporting, and grant compliance purposes. My information will be kept confidential to the extent permitted by law. I agree Submit
