AAWDC Common Intake Application

Referred By: *

AAWDC staff member or agency that referred you?

Name *

First Name Middle Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Upload one Proof of Address *

Browse Files

Examples: Driver's License, Voter Registration card, Lease Agreement, Postmarked mail addressed to you, etc.

Phone Number *

Area Code Phone Number

Email *

example@example.com

Date of Birth: *

Gender:

Male Female I do not wish to disclose

Authorized to Work in the U.S.: *

Upload one Proof of Authorization to Work *

Browse Files

Examples: Birth Certificate, U.S. Passport, W-2 form, UI Records, Paystub, DD-214, etc.

Upload one Proof Social Security Info *

Browse Files

Examples: Social Security card, W-2 form, Employment records, Paystub (Full SS# must be on document)

Race - Ethnicity

Hispanic or Latino American Indian/Alaskan Native Hawaiian Native/Other Pacific Islander Asian White African American I do not wish to answer

Do you have a disability?

Yes No I do not wish to disclose

Veteran

Yes No

Registered for Selective Service: *

Yes No Not Applicable

Are you currently employed? *

If currently employed, *

If employed, upload 2 recent paystubs

Browse Files

Receiving Unemployment Insurance? *

Recent Employment History *

Employer

Street Address Line 2

City State

Job Title

Start & End Date: *

Start date and End date

Wages/Salary: *

Reason for leaving:

If not currently working for this company

Education: *

Are you currently enrolled?

Please check your highest level of education completed

Public Assistance: Have you or a member of your family received in the last 6 months these benefits:

Temporary Cash Assistance (TCA) Supplemental Nutrition Assistance Program(SNAP) Supplemental Security Income (SSI) General Assistance Refugee Cash Assistance (RCA) Social Security Disability Insurance (SSDI)

Barriers to Employment: Checking "Yes" to these questions will have no impact on your eligibility but may qualify you for additional services:

English Language Learner Basic Skills Deficient/Low Literacy Levels Homeless Ex-Offender/Involvement in the Criminal or Juvenile Justice System Displaced Homemaker Within 2 years of exhausting TCA lifetime eligibility Single Parent Cultural Barrier to Employment Migrant and Seasonal Farmworker

Additional Barriers

No access to a computer No access to the Internet Childcare

Which H.I.T.C.H industry interests you? *

Healthcare, Information Technology, Transportation, Construction, Hospitality

If you selected "Other", what industry are you interested in pursuing?

Are you interested in taking a Computer Fundamentals course? If so, what type?

Microsoft WORD Microsoft EXCEL Microsoft PowerPoint Microsoft Publisher

What time of day is convenient for you to take a Computer Fundamentals course?

Morning Afternoon Evening

Do you need assistance with childcare?

Yes No

Name of Child

Child's Age?

Are you the parent or guardian of the child?

Yes No

Name of school of childcare center?

Intend to join or already enrolled

What is the size of your family? *

Please indicate how many family members are in your household

Select the range of your family income *

0 - $38,832 $38,833 - $57,288 $57,289 - $87,720 $87,721 - $105,444 $105,445 - Higher

By signing below you are attesting that the information above is true and correct to the best of your knowledge. *

Signature *

Clear

Date