Stepping Forward Works - Program Interest Form
Personal Information
Name
*
Date of Birth
*
/
Month
/
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Format: (000) 000-0000.
Email
*
Race/ Ethnicity
*
Black/ African American
Hispanic or Latino
Caucasian
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Other
What is your current living situation? (Check all that apply)
*
Renting
Living with Others (Family)
Living with Others (Friends/ Roommates)
Home Owner
Public Housing
Homeless
Do you have children
*
Yes
No
If yes, do they reside with you?
Yes
No
Please list all children that reside with you and their ages?
Do you receive Public Assistance?
*
Yes
No
Type of Assistance
Are you on Disability?
*
Yes
No
Type of Disability
Did you serve in the military?
*
Yes
No
Have you been convicted of any offense?
*
Yes
No
If yes, as an adult or youth?
Adult
Youth
Both
Did you serve time?
Yes
No
When did you serve?
Do you agree to take a drug test?
*
Yes
No
Do you struggle with paying bills?
*
Yes
No
Do you consider yourself low income?
*
Yes
No
Do you have a valid driver's license?
*
Yes
No
Do you have access to a vehicle or reliable transportation?
*
Yes
No
Up to how far are you able to travel forwork?
*
1 mile
5 miles
10 miles
30 miles
How did you hear about this program
*
What course are you interested in and why?
*
What is your goal when you complete this course?
*
Are you currently working?
*
Yes
No
Where do you work?
Do you work part-time or full-time?
Part-time
Full-time
When did you start working there?
What is your salary?
Ex. $15/hour, $30,000/year, etc.
Please list below your two most recent jobs (not including where you work now, if applicable). Please include the company name, dates worked, and reason you no longer work there:
*
Education: High school or GED
School or Institution
*
City, State
*
Year
*
Submit
Should be Empty: