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.
Cancel
of
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.:
*
U.S. Citizen
Permanent Resident
Alien/Refugee status
Upload one Proof of Authorization to Work
*
Browse Files
Examples: Birth Certificate, U.S. Passport, W-2 form, UI Records, Paystub, DD-214, etc.
Cancel
of
Upload one Proof Social Security Info
*
Browse Files
Examples: Social Security card, W-2 form, Employment records, Paystub (Full SS# must be on document)
Cancel
of
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?
*
Yes
No
If currently employed,
*
Full-Time
Part-Time
If employed, upload 2 recent paystubs
Browse Files
Cancel
of
Receiving Unemployment Insurance?
*
Yes
No
Yes, benefits exhausted
I am not eligible for unemployment insurance benefits
Recent Employment History
*
Employer
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Job Title
Start & End Date:
*
Start date and End date
Wages/Salary:
*
Reason for leaving:
If not currently working for this company
Education:
*
High School
Alternative School
College
None
Are you currently enrolled?
Please check your highest level of education completed
No High School
High School Diploma
Technical/Vocational
GED/High School Equivalency
Associate Degree
Bachelor Degree
Certificate of High School Completion
Some post-secondary education(college)
Post-baccalaureate degree
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
Other
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?
Pre-K or younger
Kindergarten thru 5
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
-
Month
-
Day
Year
Date
Submit
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