Fresh Start Application

Fresh Start Application
Fresh Start helps build strong communities by involving young adults, ages 17 to 25, in the construction and rehabilitation of homes in western Wisconsin.

Fresh Start combines classroom instruction to help young adults complete studies for their high school diplomas, GED, or HSED, with other educational goals, including independent living skills and the actual "hands on" construction work.

Fresh Start is a program of Western Dairyland EOC, Inc.

When you submit this form, it will not automatically collect your details, like name and email address, unless you provide them yourself.

Some fields are required.

Please complete all sections to the best of your ability. This should be filled out by the Fresh Start applicant themselves.
- Name*
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- Email*
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.
- Your Birth Date
  
  MonthDayYear
  Date
- For program enrollment, you will need to provide your birth certificate, Social Security card, and a photo ID (school ID will not count). Do you have access to ALL of these documents?
  
  YesNoOther
- Select the highest grade you have completed in school
  
  1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade (High School Graduate)GED or HSEDOther
- High School Attended
  Please include the name and location of the school
- Who is your counselor at school?
- High School Graduation Date (or expected graduation date)
  
  MonthDayYear
  Date
- Additional School, College, or Training
  Please include name of schools, locations, dates attended and dates of graduation if applicable
- Have you ever served in the Armed Forces?
  
  YesNo
- Which branch and when did you serve?
- Have you ever been convicted of a crime or placed under court supervision?
  
  YesNo
- Please explain
- Do you have a valid Wisconsin drivers license?
  
  YesNo
- Do you have access to a reliable vehicle?
  
  YesNo
- What will be your method of transportation for getting to and from programming? Our address is 1 Better Way STE A, Eau Claire, WI 54701
- Emergency Contact Information
  Name, address, and phone number of the person we will notify in case of an emergency
- Please provide information about your most recent jobs.
- Have you ever held a job?
  
  YesNo
- Have you held a job within the last month?
  
  YesNo
- Employer/Company Name & Address
- Job Title
- Describe you job duties and responsibilities:
- Name of Supervisor
- Phone Number of Supervisor
  Please enter a valid phone number.
- Date Employment Started
  
  MonthDayYear
  Date
- Date Employment Ended
  
  MonthDayYear
  Date
- Beginning Wage
- Ending Wage
- Reason for leaving this job:
- Employer/Company Name & Address
- Job Title
- Describe you job duties and responsibilities:
- Name of Supervisor
- Phone Number of Supervisor
  Please enter a valid phone number.
- Date Employment Started
  
  MonthDayYear
  Date
- Date Employment Ended
  
  MonthDayYear
  Date
- Beginning Wage
- Ending Wage
- Reason for leaving this job:
- Employer/Company Name & Address
- Job Title
- Describe you job duties and responsibilities:
- Name of Supervisor
- Phone Number of Supervisor
  Please enter a valid phone number.
- Date Employment Started
  
  MonthDayYear
  Date
- Date Employment Ended
  
  MonthDayYear
  Date
- Beginning Wage
- Ending Wage
- Reason for leaving this job:
- Reference #1
  Name, address, phone number, relation
- Reference #2
  Name, address, phone number, relation
- Reference #3
  Name, address, phone number, relation
- May we contact your references?
  
  YesNo
- Please explain
- May we contact your current/previous employer?
  
  YesNo
- Please explain
- What kind of work are you interested in doing while at Fresh Start and after?
- What would you like to accomplish at Fresh Start?
- How did you learn about Fresh Start?
Should be Empty: