Master Program Application

Marin City Community Development Corporation
MASTER APPLICATION

In order to serve you more effectively, please complete the following application. The more information you are able to provide the better we can help you achieve your goals. This form is secure and your privacy is our highest priority.
How did you hear about us?*

Walk-inGoogle Search or Social MediaEvent or WorkshopFamily or FriendFlyer, Brochure, NewsletterState of CA Department of Rehabilitation (DOR)Marin County (i.e., BHRS, Case Manager, Probation)Kaiser Permanente, Marin General Health, PhysicianOther
Are you a New or Returning Client or Member*

New Client / MemberReturning ClientReturning Member
SECTION ONE-Personal Information
Today's Date

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from physical)

Address or PO Box

Address Line 2

CityState / Province

Postal / Zip Code
Cellphone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone

Area CodePhone Number
Email
example@example.com
What is the best way to contact you?

PhoneEmail
Are you eligible to work in the United States?

YesNoOther
Social Security Security Number (000-00-0000)
Do you have a valid California Driver's License or California ID?

YesNo
Gender*

MaleFemaleTransgenderDecline To StateOther
Sexual Orientation*

Gay/LesbianHeterosexual/StraightBisexualPansexualQueerQuestioning or UnsurePrefer Not to AnswerOther
Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite / CaucasianDecline to StateOther
Race*

AfricanAmerican Indian / Alaska NativeArab /Middle EasternAsianBlack orAfrican AmericanHispanic / LatinXMultiracialNative Hawaiian or Other Pacific IslanderWhite / CaucasianDecline to StateOther
Primary Language Spoken at Home*

ArabicEnglishHindiJapaneseNative American LanguagesTagalog/Other Filipino DialectPunjabiRussianSpanishOther
Maritial Status*

DivorcedLiving with PartnerMarriedNever MarriedSeparatedSingleWidowedRegistered Domestic PartnershipDecline to AnswerOther
Do you have transportation to get to work?

Yes, I have an insured vehicleYes, I take public transportationNo, I need help learning about public transportationNo, I will need to walkOther
Are you a Veteran (Voluntary)*

I am a VeteranI am not a VeteranI Prefer Not to Answer
Disability (Voluntary)*

I have a disabilityI do not have a disabilityI Prefer Not to Answer
Mental Health/Illness (Voluntary)*

I am diagnosed with a mental health conditionI am not diagnosed with a mental health conditionI do not know, haver never had this checkedI Prefer Not to Answer
What best decribes your current living situation?

RentingOwn a homeLiving with family or friendsShelter or temporary housingSection 8 or Subsidized HousingCurrently without shelterOther
Health Insurance*

Employment BasedMedicaid / MediCalMedicareMilitary Health CareNot InsuredPrivate Pay /Direct PurchaseState Children's Health Insurance ProgramState Health Insurance for AdultsDecline to StateOther
Have you ever been convicted of a felony?

YesNoNot applicableI Prefer Not to Answer
Have you ever been convicted of misdemeanor?

YesNoNot applicableI Prefer Not to Answer
If yes to felony or misdemeanor, please briefly describe so we can better assist you with employment services:
Are you currently on probation or parole?

YesNoNot applicableI Prefer Not to Answer
I would like to learn more about Clean Slate Program.

YesNo
SECTION TWO-Programs and Services

Please select the programs and services that interest you. Our team will review these and provide other recommendations as we design your person centered service plan.
Program(s) Interested in*

Career and Workforce DevelopmentConstruction Trades ProgramPowerUp Youth Program (Ages 15-25 years. Parents must sign application for youth under 18 years of age.)Empowerment Clubhouse Program-Mental HealthSmall Medium Enterprise (SME)State of CA Department of Rehabilitation Program (DOR)Other
Service(s) Interested in*

Financial LiteracyDigital LiteracyTutoringGeneral Education Diploma (GED) SupportTax ServicesCredit CounselingTransportation EducationLegal Services Misc. Referral(s)Clean Slate Program ExpungementsChild Support ServicesFinding ShelterCase Management Referral(s)Homeownership Education ProgramsMental Health SupportCommunity Volunteer ActivitiesBenefits Planning Outreach & Assistance (BPAO) and Ticket to Work (DOR) Referral and Education. Services are typically for DOR Clients who may be receiving Supplemental Security Income (SSI) and interested in returning to work but are concerned about losing income or medical benefits.Other
State of CA DOR (Voluntary Question)

I am NOT a former DOR ClientI am a DOR ClientI have received DOR Services within the past 12 monthsI want to learn more about DORI decline to answer
My DOR Counselor is (Name):
My DOR Counselor Phone:
My DOR Counselor Email:
Comments
SECTION THREE-Household Information

List ALL Children/Dependents; including non-custodial. List ALL Adults in Household.

	Name (First and Last)	Relationship	Age	If Minor Child, do you have custody?	Veteran Status
1.
2.
3.
4.
5.
6.

Family Type*

Multi-generational HouseholdNon-related Adults with childrenSingle Parent FemaleSingle Parent MaleSingle Person (no children in household)Two or More Adults (no children in household)Two Parent HouseholdDecline to AnswerOther
# of Adults in Household*
# of Children in Household*
# Seniors in Household*
Estimated Household Annual Income*
SECTION 4-Your Support System

Please list individuals you consider to be in your support system and if you would like to have them involved in your services here at Marin City CDC. Please note that you will need to provide us with a signed Authorization of Release prior to us contacting any individuals. Marin City CDC will nor contact individuals without your consent on file.

List Names Below

	Person First and Last Name	Relationship (Case Mgr, Parent, etc.)	Phone	Email Address
1.
2.
3.

INTERNAL OFFICE USE! RELEASE OF INFORMATION RECEIVED

Yes, signed and on file.No, not signed. Do not contact.N/A
Comments
Reliable Contact (for Clients 18 years of age and over).

Please list someone we may contact if we cannot reach you?
Reliable Contact

First NameLast Name
Reliable Contact Phone:

Area CodePhone Number
Reliable Contact Email:
example@example.com
What is the best way to contact them?
Parent or Guardian Contact Information (for youth under 18 years of age)
Please select Parent, Guardian, or Not Applicable

Parent(s)Guardian(s)Other
Parent/Guardian #1

First NameLast Name
Cell Number

Area CodePhone Number
Secondary Number

Area CodePhone Number
Parent/Guardian #2

First NameLast Name
Cell Number

Area CodePhone Number
Secondary Number

Area CodePhone Number
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the best way to contact them?
SECTION FIVE-Education and Employment
What is your Current Employment Status?

Employed Full-timeEmployed Part-timeEmployed (multiple jobs)Seeking to return to labor forceTemporary or seasonal workRetiredUnemployed (less than six months)Unemployed (over six months)Other
Your Goals *
Short and long term goals.
My Goals

I want to get a part-time jobI want to get a full-time jobI want an on-call jobI want a Temporary or Seasonal jobI am open to any type of workI want to return to school and get my GEDI want to return or enroll in collegeI want to enhance my job skills to move up in my careerI want to learn new skills and get a new careerI want help with job explorationI want to learn more about Transitional Employment and Supportive Employment.I need help planning and setting my goalsOther
Are you available to work?

Yes, I am available now to workNo, I need time to build up my skills.Other
What shifts are you looking for?

MorningEveningDayOvernightWeekendsAny and all shifts that may be availableOther
Highest Level of Education

I am currently attending high schoolI am NOT attending high schoolI am currently attending collegeHigh School GraduateGEDGrades 0-8Grades 9-12 / Non-graduateHigh School Graduate + Some CollegeAssociates DegreeBachelors DegreeMaster's DegreeTrade / Vocational CertificationDecline to AnswerOther
What industries do you have experience in?

Information TechnologySolar, Green Business SectorHealthcareConstructionFinancial ServicesCustomer ServiceHospitalityRetail SalesFood ServicesNonprofit or Social ServicesPublic UtilitiesOther
I have completed

Vocational trainingApprenticeship Program(s)Professional CertificatesOther
Please describe your training received:
What I need help with:
SECTION SIX-Benefits and Income

What are your current sources of income?
Please check all that apply

Part-time EmploymentFull-time EmploymentSelf-EmploymentTemporary EmploymentUnemploymentPensionGeneral AssistanceSocial SecurityCalWORKS/TANFSSI or SSDIAlimonyChild SupportStudent Financial AidOther
What is your approximate Gross income before taxes?
Do you receive Food Stamps/SNAP?

YesNoDon't know
If yes, how much?

	Do you and the following members of your household have health coverage, including private, employer provided, and/or public (i.e., MediCal, Healthy Families, or Healthy Kids & Young Adults?)
You
Your Children
Your Spouse/Partner

Do any of your friends, relatives, or anyone else you have a relationship with work for Marin City CDC? (Staff, contact Supervisor for additional information.)

Yes, I have family, friend(s), or relationship with an individual(s) who works for Marin City CDCNo, I do not have any family, friends, or relationships with individuals who work for Marin City CDC.Other
SECTION SEVEN-Financial Information

Please complete the following to the best of your knowledge. Our financial literacy coach will provide resources and training to help contribute to your future.
Which of the following accounts do you have?

CheckingSavingsInvestmentRetirementEducation SavingsDebit CardOnline bankingMobile BankingI do not have a bank accountOther
Approximately how much do you have in total, including cash?

$1.00-$1,000$1,001-$2,500$2,501-$5,000$5,001-$10,000$10,001 and aboveDecline to AnswerOther
Do you currently owe money on any of the following? Check all that apply.

Auto LoanChild SupportCredit CardLoan from Family or FriendMedical Bill(s)Mortgage or RentPayday LoanSchool LoanTax DebtUtility Bill(s)No DebtDecline to AnswerOther
If you owe money, what is your estimated debt?
Do you know what your Credit Score is?

YesNoI don't know how to do thisI need help understanding how this works
If yes, what is your Credit Score?
During the last 12 months, have you...?

Been behind in your monthly bills?Used a credit card to pay for your regular bills?Paid cash to cash a check?Paid for a PayDay Advance?Taken a loan or had help from family and friends?Used Student Financial Aid for non-educational purposes?None of the above
Did you file a Tax Return last year?

Yes, I did my own taxesYes, I went to a free tax preparation siteYes, I paid to have my taxes filedYes, a friend or family member did my taxes for freeNo, I did not fileI need help with my taxesI owe taxesOther
Do you own a business?

YesNoOther
Do you have an ITIN for your business?

YesNoOther
Do you have any questions or concerns about your current or past tax liability?
SECTION EIGHT-Informed Consent and Acknowledgement

Thank you for choosing Marin City CDC to be your community partner in helping you achieve your goals. As part of your application process, you will receive a copy of our Privacy Policy, Rights of Persons Served, and Accessibility Policy. In addition, and according to the programs and services you are enrolled and participate in, you will receive and sign appropriate documents for your review and success.
Date

MonthDayYear
Date
Applicant Signature

Clear
Parent/Guardian Signature (for anyone under age 18)

Clear
Thank you for completing the MCCDC enrollment process!

Please print this form and sign it using the space(s) above, then submit to MCCDC Program or other designated staff.
Should be Empty:

Marin City Community Development Corporation

MASTER APPLICATION

SECTION ONE-Personal Information

SECTION TWO-Programs and Services

SECTION THREE-Household Information

SECTION 4-Your Support System

Reliable Contact (for Clients 18 years of age and over).

Parent or Guardian Contact Information (for youth under 18 years of age)

SECTION FIVE-Education and Employment

SECTION SIX-Benefits and Income

SECTION SEVEN-Financial Information

SECTION EIGHT-Informed Consent and Acknowledgement

Thank you for completing the MCCDC enrollment process!