Pathways To Excellence Program Application

  • Enrollment Form

  • Applicant Information:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Demographic Information:

    Disclosure: Please be aware that providing demographic information is entirely voluntary and will not impact your eligibility for services. WorkSource Montgomery (WSM) and its affiliates operate in accordance with the Equal Employment Opportunity Commission (EEOC) guidelines and the Civil Rights Act of 1964. We do not discriminate based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other protected characteristic.
    • Click For Section II 

    • On March 11, 2021, the American Rescue Plan Act was signed into law, and established the Coronavirus State Fiscal Recovery Fund and Coronavirus Local Fiscal Recovery Fund, which together make up the Coronavirus State and Local Fiscal Recovery Funds (“SLFRF”) program. This program is intended to provide support to State, territorial, local, and Tribal governments in responding to the economic and public health impacts of COVID-19 and in their efforts to contain impacts on their communities, residents, and businesses. Individuals entering ARPA services may self-attest to the impact caused by the COVID-19 Pandemic below:

    • 1. Have you, a parent/guardian, or other adult household member loss employment due to the COVID pandemic?*
    • 2. Have you, a parent/guardian, or other adult household member loss hours/wages due to the COVID pandemic?*
    • 3. Have you, a parent/guardian, or other adult household member loss childcare due to the COVID pandemic?*
    • 4. Were you, a parent/guardian, or other adult household member facing eviction, housing insecurity or homelessness due to the COVID pandemic?*
    • 5. Were you, a parent/guardian, or other adult household member unable to obtain employment due to business closures or economic downturn due to the COVID pandemic?*
    • 6. Were you, a parent/guardian, or other adult household member unable to enroll in virtual training/education due to the inability to obtain electronic devices, WIFI/Internet or any other digital barrier since the onset of the COVID pandemic?*
    • 7. Have you, a parent/guardian, or other adult household member had social emotional fears/anxieties due to the COVID virus? Note: You are not required to disclose medical, private, or HIPAA related information.*
    • 8. Have you, a parent/guardian, or other adult household member had death/illness/ on-going health symptoms due to the COVID virus? Note: You are not required to disclose medical, private, or HIPAA related information.*

    • Self-Attestation Statement:

    • I certify that the information provided on this document is true and accurate to the best of my knowledge and belief. I understand that such information is subject to verification and further understand that the above information, if misrepresented or incomplete, may be grounds for immediate termination from any ARPA program and/or penalties as specified by law.

    • DATE*
       - -
    • Are you under the age of 18?*
    • DATE*
       - -
    • Is the form being filled out with a staff person present?*

    • Staff Verification Statement:

      I certify that the information provided on this document is true and accurate to the best of my knowledge and belief. I understand that such information is subject to verification and further understand that the above information, if misrepresented or incomplete, may be grounds for immediate termination from any ARPA program and/or penalties as specified by law.
    • DATE*
       - -

    • This form is submitted digitally and remitted to Pathways To Excellence, Inc.

      Pathways To Excellence will make this information available to WorkSource Montgomery, who may verify your participation in Pathways To Excellence, Inc's programs and activities.


      Erica Roberts
      Executive Director
      Pathways To Excellence, Inc.

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