Getting to Know You
Personal Information
Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Non-Binary
Date of Birth
*
/
Day
/
Month
Year
Contact Information
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment & Education
Employment Status
*
Self - Employed
Seasonal Employment
Full-Time
Unemployed
Part-Time
Are you a student?
*
Please Select
Full-time
Part-time
No
Do You have a diploma or GED?
*
Please Select
Yes
No
Highest level of education completed:
*
Please Select
High School
Some College
Trade
Associates Degree
Bachelors Degree
Doctorate Degree
Are you willing to do job trainings or community based learning programs?
*
Please Select
Yes
No
Please upload a resume if seeking employment resources
Browse Files
Drag and drop files here
Choose a file
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Current Circumstances
Current living situation
*
Please Select
Stable
Renting, facing eviction
Renting, served with eviction notice
Staying with family or friends "crashing"
Weekly or short-term housing
Do you have any dependents or children for whom you are currently responsible?
*
Please Select
Yes
No
If so, how many and what ages?
Marital Status
*
Please Select
Single
Married
Common Law
Widowed
Divorced
Do you have access to transportation?
*
Please Select
Yes
No
What is your immediate need?
*
Please Select
Rental assistance
Utility assistance
Food or groceries
Employment resources
Childcare resources
Healthcare resources
Other
If you selected other, please explain below
What is it you hope to achieve with Obodo?
*
Do you receive support services from any other organization?
*
Please Select
SNAP/EBT
WIC
SSI
Unemployment
Retirement Fund
Other
What service providers have you contacted?
*
Did you receive services?
*
Please Select
Yes
No
If no, why not?
Are there any other factors that you are facing that are not listed above?
How did you hear about us?
*
Please Select
Instagram
Facebook
Website
Friend
Referral
Community Event
Referral Name
By clicking "YES" below, you willingly consent to participate in the programs and services offered by The Obodo Collective, demonstrating your commitment and willingness to participate with any relevant suggestions or requirements.
*
Please Select
Yes
No
Date
-
Month
-
Day
Year
Date
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