Referred By:(Required) Cherry Street Mission A Renewed Mind Harbor Zepf Unison Radio Billboard Social Media Word of Mouth Other APPLICANT'S INFORMATIONName(Required) First Last Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone(Required)Date of Birth(Required) MM slash DD slash YYYY BREAKING DOWN BARRIERS & GETTING TO KNOW YOUDo you have a High School Diploma or GED?(Required)Your answer will not affect program eligibility. HS Diploma GED None Are you interested in support for GED prep?(Required)Your answer will not affect program eligibility. Yes No Do you have reliable transportation to attend class / employment?(Required)Your answer will not affect program eligibility. Yes No My means of transportation is:(Required) Do you need transportation assistance?(Required)Your answer will not affect program eligibility. Yes No Do you have childcare?(Required)Your answer will not affect program eligibility. Yes No Not Applicable My means of childcare is:(Required) Are you interested in childcare assistance?(Required)Your answer will not affect program eligibility. Yes No Are you interested in mental health assistance?(Required)Your answer will not affect program eligibility. Yes No Are you interested in substance abuse assistance?(Required)Your answer will not affect program eligibility. Yes No Are you interested in legal assistance?(Required)Your answer will not affect program eligibility. Yes No Are you interested in budgeting assistance?(Required)Your answer will not affect program eligibility. Yes No Do you have any felonies?(Required)Answering "Yes" will not disqualify you from the program. Yes No Type(Required) Are you currently employed?(Required)Your answer will not affect program eligibility. Yes No Days/Times(Required)What barriers are keeping you from being employed?(Required)Do you need temporary employment while attending Workforce Development class?(Required)Your answer will not affect program eligibility. Yes No Which class are you interested in?(Required) Auto Tech Building and Trades Culinary Customer Service Digital Literacy Manufacturing Technician Pre-GED Welding Tool and Die After you graduate, what are your career goals?(Required)Are you able to sit for 8 hours a day?(Required) Yes No Are you able to stand on your feet 8 – 10 hours a day?(Required) Yes No Do you have any physical limitations?(Required) Yes No Explain(Required)Do you enjoy working with computer technology?(Required) Yes No Rate your computer skills(Required) Not Familiar Somewhat Familiar Very Familiar Do you enjoy working with tools mechanical in nature?(Required) Yes No How successful are you completing tasks?(Required) Not Successful Somewhat Successful Very Successful Do you enjoy setting goals?(Required) Yes No Do you consider yourself an active listener?(Required) Yes No Does problem solving interest you?(Required) Yes No Do you enjoy talking on the phone?(Required) Yes No Does working in a collection agency interest you?(Required) Yes No Do you enjoy people and working with them?(Required) Yes No Do safety practices interest you?(Required) Yes No How successful are you with having a backup plan?(Required) Not Successful Somewhat Successful Very Successful Are you ready to seek employment in the vocational field of interest?(Required)Your answer will not affect program eligibility. Yes No Not Now CAPTCHA
