ENGAGE Enrollment Form - Workforce Development (BENEFITS)

ENGAGE Enrollment Form - Workforce Development (BENEFITS)
Welcome to the ENGAGE Workforce Development Program! We provide intensive support to help clients find and keep meaningful employment. Please complete all of the information below to enroll in this exciting and effective program!

***BEFORE YOU BEGIN, you will need a copy of all the documents below.***
Below, please upload a copy of your government-issued ID. *

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Below, please upload a Summary of Benefits (must show the child's name and your address). Other examples include verification that you receive cash, food Medicaid, or publicly-funded childcare assistance through Lucas County Job and Family Services. *

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Name*

First NameLast Name
Date*

MonthDayYear
Date
Workforce Support Intake
Section 1: Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Gender*

MaleFemaleNon-binary
Date of Birth*

MonthDayYear
Date
Do you or any of your family members participate in any of these Center of Hope Programs:*

Family NavigatorNurturing ParentsENGAGEELEVATE Afterschool ProgramNone
How did you hear about us?*

Internet (Google Search)Social MediaReferral
If you heard about a program from a referral, please list their name (otherwise, type "None")*
Race/Ethnicity*

Hispanic/LatinoAmerican Indian or Alaskan NativeAsianWhiteHawaiian Native or Pacific IslanderBlack/African-AmericanOther
Do you have minor children living in your home?*

YesNo
What are their ages?*
Do you have a child support order?

YesNo
Section 2: Educational Background Information
Name of the last school you attended:*
Dates of the last school you attended:*
Highest grade you completed:*
Are you currently in a GED program?*

YesNo
Please list the name of the GED program. Otherwise, enter "NA" in the box below:*
Do you want to continue with school or training after finishing high school or earning your GED?*

YesNoNot SureNot applicable
If you wish to continue with school or training after finishing high school or earning your GED, please select the type of program:

6-8 months training certificate2-year college degree4-year college degreeGraduate degreeMilitary serviceNot applicable (I do not wish to continue with school)
Section 3: Job Training and Work Experience
Have you taken any vocational or construction education classes?*

YesNo
If yes, please describe where and when. Otherwise, enter "NA" in the box below:*
Have you taken any machine shop classes?*

YesNo
If yes, please describe where and when. Otherwise, enter "NA" in the box below:*
Have you completed any other types of training programs?*

YesNo
If you you have completed another type of training program, please specify the type. Otherwise, enter "NA" in the box below:*
Section 4: Employment History
Have you ever been employed?*

YesNo
Most recent job title*
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Describe your job duties. If you've never been employed, please enter "NA" in the box below:
Name of Employer*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone Number*
Please enter a valid phone number.
Average number of hours worked per week:*
Hourly Wage:*
If you are no longer employed there, why did you leave? If you are still there, type "NA" in the field:*
May we contact your employer as a reference?*

YesNo
If you had additional employment, please list your job title, start and end dates, duties, the name of the employer, address, phone number, hours worked per week, hourly wage, why you left, and whether we may contact your previous employer as a reference. Otherwise, please enter "NA" in the field below:*
Please check all the experience/skills you have:*

PlubmingElectrical WiringSheet MetalRoofingDrwallPower ToolsPersonal ComputersExcelWeb DesignLift TruckPaintingRough CarpentryFinish CarpentryMechanical RepairHousing RehabilitationMS WordPowerPointCAD EquipmentOther
How comfortable are you with using computers*

Very (I can run programs, surf the web, etc.)Somewhat (I can type papers and send some email)I don't really use computers
List any other tools/machines you have operated:*
Section 5: Physical Information
Do you have any physical, medical or other health problems (including allergies) that would affect your ability to do the activities needed to perform any specific type of work?*

YesNo
If yes, please describe:*
Section 6: Emergency Contact
Emergency Contact's Full Name*
Emergency Contact's Relationship to You*
Emergency Contact's Phone Number*
Please enter a valid phone number.
Please list the name and phone number of someone who can always reach you:*
Section 7: Certification and Signature
I certify that the information in this application is true and correct to the best of my knowledge. I also authorize the WSOS staff to verify this information when reviewing my eligibility for the program. I understand that I may be asked to provide documentation and agree to sign ifasked, one or more release forms to allow United North to verify the information provided in this application. *

Clear
Date*

MonthDayYear
Date
Client Goals and Case Plan
Name of Client*

First NameLast Name
Date of Case Plan*

MonthDayYear
Date
Are any of these barriers for you?*

HealthFoodChild Support/CustodyAccess to mental health servicesEducationHearing Support/Attorney ReferralsCSEA/LCJC Paperwork HelpSupport at my child's schoolQuestions about my child's school or progress at schoolMental HealthSubstance Abuse DependencyAge FactorsDisabilitiesLack of /Limited TransportationBackground checkLimited/No Work HistoryNo Job SkillsNo Driver's LicenseSocial IsolationLimited/No Jobs AvailableHomelessnessOther
What are your strengths?*
Goals/Action Steps (Please check the goals you'd like to complete)*

Job searchVolunteer work experienceJob sampling/Job shadowingOn-the-job trainingEmployment counselingRegistration with local job serviceJob readinessHigh school diplomaGEDESL (English as a second language)Adult vocational trainingLiteracy improvementHigher educationLife skills activitiesParenting skillsChildcare assistanceChild supportSubstance abuse treatmentCounselingDriver's license reinstamentDental/health careSSA ApplicationMedical reportDecision lettersLegal AssistanceCare for child under age 6Other
Which date do you think you'd have the goals completed (with our help):*

MonthDayYear
Date
Please check the box after you have read and understand:*

I understand that the purpose of this plan is to meet the identified goals through specific steps and I am required to follow the steps developed. I understand that I must participate in work activities and/or other activities and referrals developed in this plan. Failure to follow through may constitute removal from the program. I also understand that if there are any changes to be made that I will contact case worker in a timely manner to ensure my success in this program.
Please check the box after you have read and understand:*

I understand that the purpose of the case plan is to follow through with goals listed (i.e., accessing other resource programs, keeping medical apps, et.). Failure to follow through with the steps identified in the case plan may constitute suspension from the General Assistance Program.
Signature*

Clear
Date*

MonthDayYear
Date
Photo/Video Release
I, Full Name*, grant permission to Center of Hope Family Services, Inc. and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium.

I hereby release Center of Hope Family Services, Inc. and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.

I acknowledge that I am over the age of 18 and the legal guardian of the child.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

Clear
Improving the life outcomes of adults, children, and families in urban settings.

419.861.4400 | 5461 Southwyck Blvd. Toledo, OH 43614 | www.cohfs.org
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ENGAGE Enrollment Form - Workforce Development (BENEFITS)

Photo/Video Release