STUDENT INTAKE FORM
Name
*
First Name
Last Name
Date of Birth:
*
/
Month
/
Day
Year
Date
Are you a veteran?
Yes
No
SSN/ Tax ID
*
Contact our office if you have a question about this requirement
Are you a returning student to this program?
*
Yes
No
Primary Program
*
Electricity 1
Construction
Other
Address Information:
*
Street Name and Number
Apartment Number:
City:
*
State:
*
Zip Code:
*
County or Ward:
*
Cell phone number:
*
Other Number:
Email Address:
*
example@example.com
Name Emergency Contact
*
First Name
Last Name
Relationship
Phone Number
*
Zip Code
Demographic Information - Gender
*
Female/ Male/ Other
Country of Origin
*
Race?
*
American Indian or Alaskan Native:
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Unknown
Prefer not to Answer
Other
Hispanic/Latino
Yes
No
Housing Category:
*
Own
Rent/lease
Subsidized
Public Housing
Section 8
Other
Housing Status:
*
Own
Rent/lease
Living with relatives
Living with non-relatives
Homeless
Other
Date of Arrival in US (if US Citizen put Date of Birth)
*
/
Month
/
Day
Year
Date
Date of Arrival in DC/MD (if US Citizen put Date of Birth)
*
/
Month
/
Day
Year
Date
Status:
*
Refugee
Asylee
Immigrant
DACA
Cuban Haitian Entrant
TPS
Victim of Human Trafficking
Amerasian
Secondary Migrant
Citizen
Resident
Born in the US
Returning Citizen?
No
Yes - Local
Yes - Federal
Barriers: (Click all that apply)
*
Safety
Health/Medical
Family
Education
Employment
Housing
Financial
Food
Clothing
Transportation
Legal
Utilities
What type of job are you looking for? (Click all that apply)
*
Part time
Full time
Mornings
Afternoons
Evenings
Weekends
Contract
Temporary
Live in
Volunteer
Other
Not applicable
Do you have any work restrictions?
Yes
No
Can't stand for long periods
Disabled
Hearing Impaired
Physical limitations
Sight limited
Must work indoors
Work History: Employer Name
Employer Address
Begin Work Date
/
Month
/
Day
Year
Date
Job Title
Industry
Hourly Salary
Payment Schedule
Hourly, daily, weekly, bi-weekly, monthly
Household Monthly Income:
*
Less than $500
$500 - $1000
$1001 - $1500
$1501 - $2000
More than $2000
Other:
Do you have a resume?
Yes
No
Would you like assistance with either updating or creating a resume?
Yes
No
List Any Professional Associations
Highest Education Level Completed on Entry:
*
0 – 7
8 – 12
Some high school
GED/HS Diploma
Some college
College Degree
Post Graduate
Military
Technical/Vocational
Education Completed Outside of the US?
*
Yes
No
Name of last school attended:
Have you taken the GED before?
*
Yes
No
If yes, when:
Primary Language:
*
English Language Level
*
Beginner
Intermediate
Advanced
Strengths
Transportation
*
Own Car
Rental Car
Borrowed Car
Public Transportation
None
Do you have a driver's license?
Yes
No
Driver's License State and Title
Driver's License Number
Expiration Date
/
Month
/
Day
Year
Date
Type of Driver's License
Regular
CDL - B
CDL - A
Public Assistance Status:
*
Not applicable
TANF Recipient
Food Stamps/SNAP
Medicare
Medicaid
WIC
SSDI
SSI
Other:
Occupation:
*
Professional
Clerical
Technical
Service
Agriculture
Homemaker
Sales
Student
Other:
Voting Behavior
*
Registered to vote
Registered, but Never Voted
Not Registered to vote
Check all that apply
*
Cultural Barriers
Low Income
English Language Learner*
Exhausting TANF within Two Years
Foster Care Youth
Long Term Unemployment
Single Parent or Guardian
Dislocated Worker
Minor with adult status
Other
Referral Source
*
TV/Radio
D.O.E.S.
Friend/Family
Employer/School
Library
Other adult ed. organization
Other agency
Library Hotline
Church
Power/ad
PR talk/presentation
Special event
Newspaper:
Other
By writing my full name and submitting this form, I acknowledge that I am registering for one of the Catholic Charities Program. I understand that I must follow all requirements for the program and fulfill my enrollment financial obligation (if applicable) in order to participate in the courses. I also acknowledge that space is limited and my application is evaluated based on seats available.
*
Enrollment Entry Date: * FOR OFFICE USE ONLY * (Do not enter information)
/
Month
/
Day
Year
Date
Program:
Staff Conducting Intake:
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