DayWorkerIntakeForm

Legal
Have you ever been convicted of a crime ?*

YesNo
Type of conviction
Are you currently or have you ever been on probation?*

YesNo
Year of conviction
Are you currently or have you ever been on parole?*

YesNo
Year of conviction
Probation/Parole Officer's Name
Probation/Parole Officer's Phone #
Probation/Parole Officer's E-mail
Would you like a referral for legal services (expungement, taxes, court, legal aid)?

YesNo
Please list what you would like help with:

Terms and Conditions
Please read carefully:

The undersigned agrees to be bound by all the rules governing the LEAN Program and in addition agrees to the following:

1. Waive any and all claims against the LEAN Program , its Board Members, employees, and agents for any liability or loss (including but not limited to bodily injury arising out of the operation of the LEAN Program).

2. Indemnity to hold harmless the LEAN Program employees and agents from any and all claims, demands, liability or loss (including, but not limited to, legal expenses or court costs which may arise from or be incurred as a result of any referral of a worker or workers through the LEAN Program). This includes all claims of malfeasance or nonfeasance on the part of the LEAN Program, its board members, employees, and agents.

By my electronic signature below, I agree to the LEAN Program governing policies and the agreement above.
The Undersigned Client Certifies That:*

All of the above statements are true and completeI have read and agree to follow the rules of the LEAN ProgramI understand that any violation will not be tolerated and will suspend my use of the facilities at LEAN
Signature*

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For Staff Use Only
Programs
Please choose the primary program that this individual is enrolled in
Programs referred to:
Date

MonthDayYear
Staff Member:
Programs referred to:
Date

MonthDayYear
Staff Member:
Programs referred to:
Date

MonthDayYear
Staff Member:
Exit Information
Date of Exit

MonthDayYear
Please Select One
Please describe circumstances
Outcome
Certifications
Please use this space to list any relevant certifications that the individual has acquired
Employment
Employer:
Job Title:
Pay Rate:
Start Date

MonthDayYear
Hours per week
Education Continuation
School Name:
Enrollment Date:

MonthDayYear
Program of Study:
FAFSA:
Pell:
Proof in file:

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Additional Notes
Staff Signature

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Client Registration