Clover Connections Interest Form

Name* This field is required.

First Name

Last Name

Email Address* This field is required.

example@example.com

Confirm Email

Gender* This field is required.Select One

Race* This field is required.

Asian/Pacific Islander

Black/African American

Hispanic/Latino

American Indian/Native American

White/Caucasian

Multi-racial

Other

Enter Birth Date* This field is required.

Date

Last 4 digits in SSN* This field is required.

Any differently-abled conditions?* This field is required.Select all that apply

Visual and/or hearing loss

Motor Impairment(s)

Cognitive Impairment(s)

None of the above

Zip Code* This field is required.

Best Contact Number* This field is required.

Area Code

Phone Number

Best Time to Contact You* This field is required.(Select one)

Anytime Mondays through Fridays between 9am-4pm

Anytime Mondays through Fridays between 5pm and 8pm

Weekends between 10am and 2pm

Other

Career Area of Interest* This field is required.(Check all that apply)

Advanced Manufacturing

Building & Construction Trades

Healthcare

Hospitality

Information Technology

Other

What is your highest level of education?* This field is required.(Select one)

Doctorate or equivalent

Master's Degree

Bachelor's Degree

Associate's Degree,

Technical or vocational school certificate

High school diploma or high school equivalency

Less than a high school diploma or high school equivalency

If you are currently enrolled in school or any training program, what is your enrollment status?* This field is required.(Select one)

Fulltime

Parttime

Not currently enrolled in any program

Please list any areas in which you have industry-based certifications (IBCs)

Name of IBC

Were your hours reduced as a result of COVID-19?* This field is required.

YESNO

Were you laid off as a result of COVID-19? * This field is required.

YESNO

Do you have access to a smart phone with camera capabilities (to participate in a virtual interview)?* This field is required.

YESNO

Do you have access to a computer with internet and camera capabilities (to participate in a virtual interview)?* This field is required.

YESNO

Do you receive SNAP benefits?* This field is required.

YESNO

Do you have health insurance?* This field is required.

YESNO

Are you eligible for unemployment benefits?* This field is required.

YESNO

To your knowledge, do you have any family member currently being served by another Kingsley House program (Headstart, Adult Day Care, Kings of Kingsley, etc...)* This field is required.

Yes

I am not sure

Upon receipt of this information and a reveiw by Kingsley Connections staff, someone will follow up with you within 48-72 hours.

Kingsley Connections ID

Clover Connections Interest Form