ASCENDING GROWTH Participant Application & Intake Form

ASCENDING GROWTH

"Where Second Chances Take Root" Participant Intake & Assessment Form
Applicant Information
Full Legal Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Last 4 SSN
Driver's License/State ID #
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip
County
Veteran Status
Race/Ethnicity (Optional)

Other
Gender
How did you hear about Ascending Growth?

Other
Services Requested

Other
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Have you experienced any barriers that may impact employment or stability?

Other
Please briefly explain what goals you would like to work toward while participating in Ascending Growth programs/services.
Do you have reliable transportation?
Primary Transportation

Other
Do transportation challenges prevent you from:

Other
Would transportation assistance be helpful?
Do you own a smartphone?
SECTION 3: EMERGENCY CONTACT
Contact Name

First NameMiddle NameLast Name
Relationship
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 4: BACKGROUND BARRIERS ASSESSMENT
Marital Status
Number of Children in Household
Current Living Situation
SECTION 5: EMPLOYMENT HISTORY
Current Employment Status
Services Requested

Other
Please briefly explain what goals you would like to work toward while participating in Ascending Growth programs/services.
Have you experienced any barriers that may impact employment or stability?

Other
Most Recent Employer
Highest Level Completed
Interested In Additional Training?
If yes, what type?

Other
SECTION 2: PARTICIPATION AGREEMENT
I understand that Ascending Growth is designed to assist participants with personal development, workforce readiness, life skills, mentorship, peer support, and employment opportunities. I agree to:
An administrative processing fee of $25.00 may be required to process this application and associated intake documentation. Fees help support administrative operations, intake processing, document preparation, and program coordination. Submission of payment does not guarantee approval or acceptance into any program or service.
Payment
Payment
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Administrative Processing Fee
Required administrative processing fee

$25.00

Total

$0.00
Participation Agreement
Date

MonthDayYear
Date
Participant Signature
Office Use Only
8929 JM Keynes Dr., Ste 330 Charlotte, NC 28262 704-900-7488 office@ascendinggrowth.org www.ascendinggrowth.org
Date

MonthDayYear
Date
Received By
Program/Referral Source
What is your biggest challenge right now?
Should be Empty:

ASCENDING GROWTH

Applicant Information

SECTION 3: EMERGENCY CONTACT

SECTION 4: BACKGROUND BARRIERS ASSESSMENT

SECTION 5: EMPLOYMENT HISTORY

SECTION 2: PARTICIPATION AGREEMENT

Payment

Payment*

Office Use Only

Payment