Motherhood Initiative Inspire Career Education Program

Motherhood Initiative Inspire Career Education Program

Program for 17 and older. This program is for those who are entering the workforce for the first time, looking for a career change, and/or in need of essential soft skills training. Lectures are held at our main office 1920 Old Springville Road, Center Point, AL 35215.
Health and Safety Questionnaire

Please answer the health and safety questionnaire.
In the last six months, has anyone in their household had to quarantine or isolate because of COVID-19?*

YesNo
In the last six months, has anyone in their household been hospitalized because of COVID-19?*

YesNo
Have you been vaccinated with both shots?*

YesNo
Do you have any underlying health conditions we need to be aware of? (We will speak with you privately if the answer is yes to obtain more details for emergency purposes.)*

YesNo
Applicant Name*

PrefixFirst NameLast Name
Applicant Date of Birth

MonthDayYear
Date
Applicant Current Age
Applicant Phone Number*

Area CodePhone Number
Applicant E-mail*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload Identification Here

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Gender*
Ethnicity (please check one)*
Are you a legal citizen of the United States?*

YesNo
Do you have children?*

YesNo
If yes, how many?

Complete all information about your children

What was the last grade level you completed?*
Check all services needed

Education Support Services including GED/High School DiplomaEmployment ResourcesOne-to One MentoringGroup MentoringYouth Mentoring for ChildrenHuman Support Services including food, clothes, and resources
Please submit last report card/progress report

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Are you interested in obtaining your GED or High School Diploma?

GEDHigh School DiplomaUndecided

REQUIRED: This section is required for applicants under the age of 18. Please answer the required questions about guardianship. If you are over the age of 18 you may skip this section.
Guardian

PrefixFirst NameLast Name
Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Guardian Phone Number

Area CodePhone Number
Guardian E-mail
example@example.com
Is/Has participant received special education accommodations? Please select all that apply:
Is there anything else needed to share about participant education plan/services

REQUIRED: Emergency Contact Information
Emergency Contact 1

PrefixFirst NameLast Name
Emergency Contact 1 Phone Number

Area CodePhone Number
Emergency Contact 2

PrefixFirst NameLast Name
Emergency Contact 2 Phone Number

Area CodePhone Number
Upload a Copy of Medical Insurance Card: This is needed at the time of emergency and medical personnel has to be notified.

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Support Questionnaire
Do you have reliable transportation? If you do not transportation will be provided.*

YesNo
Will you need childcare? This applies to 6 week to pre-school aged children.*

YesNo
Do you need food or clothes?*

YesNo
Do you need help obtaining legal documents, identification, social security card, or birth certificate?*

YesNo

Employment Questionnare
Participant: Have you ever worked before?

YesNo
Are you currently employed?

YesNo
If yes, where do you work?
How much are you paid? Hourly, weekly, biweekly, or monthly?
Are you underemployed or not making enough on the job you currently have?

YesNoN/A
For the Participant: Tell us a little about yourself (Skills, Career Goals, Class Expectations.)*

Support Questionnaire