ECONOMIC EMPOWERMENT CLASS APPLICATION

Name*

First NameLast Name

Pronouns*

Pronouns - If OTHER, please provide more information

Date of Birth*

Date

Gender*

Race/Ethnicity*

Name of your KBFLC Advocate

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Emergency Contact 1*

First NameLast Name

Emergency Contact 1*

Please enter a valid phone number.

Emergency Contact 1 Relationship*

Emergency Contact 2

First NameLast Name

Emergency Contact 2

Please enter a valid phone number.

Emergency Contact 2 Relationship

Do you have any felony charges?*

YesNo

Have you ever been convicted of a felony? If yes, Please provide details.

Do you have any PENDING felony charges?*

YesNo

Do you have any PENDING felony charges? If yes, Please provide details.

Do you have any substance use challenges that may hinder your employment readiness?*

YesNo

If yes, Please provide details.

Have you experienced domestic or sexual violence?*

YesNo

If yes, Please provide details.

Do you have any mental health challenges?*

YesNo

If yes, please check the applicable types (select all that apply)*

If yes, please provide details.

What interests you most about the Economic Empowerment Program?*

What specific goals do you hope to achieve through this program?*

Have you participated in similar programs before? If yes, please describe your experience. Use NA if you have not. *

Are you currently employed? If yes, please provide details of your current job, including your role and work hours. If no, please use NA*

What kind of employment are you seeking (full time, part time, specific industry, etc.)*

Have you ever had challenges maintaining employment? If yes, please explain. If no, use NA. *

How confident are you in your ability to find and keep a job? *

Scale of 1-5, with 1 being not confident and 5 being very confident

Do you have a resume? If not, are you willing to work on creating one during the program?*

What is the highest level of education you have completed?*

Do you have any vocational training or certifications? Please specify. *

Are there specific skills you want to develop or improve during the program? (Computer skills, communication, time management, etc.)*

Are you currently experiencing any mental health challenges that may impact your ability to participate in this program? If yes, please explain. *

Do you have any physical health conditions that may require accommodation during the program? If yes, please describe. *

Have you ever faced challenges that might make it difficult to complete a 12 week program? If yes, please explain. *

What barriers might you be facing?

How would you rate your current mental and physical health? *

Scale 1-5, with 1 being very poor and 5 being excellent

Are you currently under the care of a healthcare professional? If yes, are they aware of your intent to participate in the program?*

Do you have a stable living situation?*

Do you have access to reliable transportation?*

Who do you consider part of your support system? (Family, friends, community organizations, etc.)*

How do you manage stress or difficult situations?*

Are there any other factors or challenges you feel might impact your ability to participate fully in the program?*

The Economic Empowerment Program is a 12-week commitment with regular meetings and assignments. Are you able to commit to this schedule?*

Do you have any upcoming commitments (family obligations, work, travel, etc.) that might interfere with your attendance or participation?*

How do you plan to manage your time to ensure you can fully participate in the program?*

Is there anything else you would like us to know about your or your situation that could help us better understand your needs and how we can support you in this program?*

Important Notice: Please be aware that completing this assessment form does not guarantee acceptance into the program. All potential applicants will be required to participate in an interview as part of the selection process. You will be notified if you are accepted into the program and provided with further details.

I will actively participate in all aspects of the program, including workshops, training sessions and assignments.
I understand that missing TWO unexcused absences or THREE EXCUSED ABSENCES during the program will result in my dismissal fro mthe program.
I understand that missing days will cause a deduction in my stipden at the end of the month.
I understand that during partipation in the program, I may be exposed to and have access to information, materials, and discussions that are confidential and proprietary to the program.
The participant agrees that they shall not, during or after their participation in the program, disclose or use for their benefit or the benefit of any third party any confidential information obtained during the program. The participant further agrees that they will not discuss, disseminate, or share any confidential information with other participants, program staff, or any external parties.
I understand that my failure to complete a full 30 days (about 4 and a half weeks) of the EEP (Economic Empowerment Program) will result in me forfeiting the receival of the stipend at the end of the month.
I understand and consent that photos takens within the program can and will be used within promotional material for the organization, and I am waiving the write to all compensation associated with those pictures.

By sigining below, I confirm that I have read and understood the conditions outlined in this application. I am committed to activitely participating in the program to enhance empolyment readiness.

Signature

ECONOMIC EMPOWERMENT CLASS APPLICATION

Personal Information

Contact Information

Emergency Contacts

Demographics

Program Interest and Goals

Employment Readiness

Skills and Education

Mental and Physical Preparedness

Personal and Support System

Availability and Commitment

Additional Information

Participation Agreement