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Adult Workforce Development Registration
Adult Workforce Development Registration
2024-03-29T12:15:46-04:00
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- Your Information
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Your Information
First Name
*
Middle Initial
Last Name
*
Email
*
Phone
*
Do you check your email often?
*
Yes
No
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Age
*
Date of Birth
*
MM slash DD slash YYYY
Social Security Number
Gender
*
Male
Female
Other
Race
*
White
Black /African-American
Latino
Asian
Hawaiian /Pacific Islander
Native American /American Indian
Do not wish to disclose
Other
National Origin
*
African
American
Asian
Central and Latin America
European
Middle Eastern
North American
Oceania
Do not wish to disclose
Other
Other Race
*
Other National Origin
*
Please check all the boxes that apply
*
Returning Citizen
Verteran
Homeless
Immigrant
None of the Above
Have you served or are currently serving in the military?
*
Yes
No
Is your spouse currently serving or has he/she previously served in the military?
*
Yes
No
Educational Background
Highest Educational Attainment
*
Some Highschool
High School Diploma or Equivalent
Some College
Associate's Degree
Bachelor's Degree
Advanced Degree
Trade School
Other
Employment Information
Are you currently employed?
*
Yes
No
Please provide the name of your current or most-recent employer?
*
What was your job title?
*
Start Date? (close as you can recall)
*
MM slash DD slash YYYY
End Date? (close as you can recall)
*
MM slash DD slash YYYY
Hourly wage/salary earned during employment?
*
Number of hours worked per week?
*
Please list any additional skills, talents or hobbies you have
*
Do you have any certifications in any of these skill areas? Please list
*
Do you have any physical limitations? If so, what are they?
*
Check all the items you currently have:
*
Please keep in mind, if you don't have any or all of the following items listed below, it is NOT a problem. We will gladly assist you in obtaining them (*including a bank account, prior to your first payday)
State Issued ID
Drivers License
Birth Certificate
Social Security Card
Bank Account
Do you have a resume?
*
Yes
No
Please help me create one
Upload Your Resume
*
Max. file size: 256 MB.
What is your transportation needs and capability? Please check all that apply
I have a car of my own
I share a car with family member
I do not have a car or access to transportation
I take public transportation
I usually just walk where I need to go
My transportation situation is a problem
Home & Surrounding Enviroment
Who lives in your home with you?
*
Mom
Dad
Step parent
Grandparent
Family Gaurdian
Sister
Brother
More than 2 siblings
Child/Children
Friend
Extendend Family Members
Friends
More than 1 Extended Family Members
How many people live in your home?
*
1
2
3
4
5
6
7
8
9
10+
Have you moved in the past 5 years?
*
Yes
No
Do you live near public grocery store? (<2 miles)
*
Yes, one
Yes more than one
The nearest is less than 5 miles away
The nearest is less than 10 miles away
No grocery store is within 10 miles
Do you live near public library? (<2 miles)
*
Yes, one
Yes more than one
The nearest is less than 5 miles away
The nearest is less than 10 miles away
No public library is within 10 miles
Do you live near a shopping mall or plaza? (<2 miles)
*
Yes, one
Yes more than one
The nearest is less than 5 miles away
The nearest is less than 10 miles away
No shopping mall or plaza is within 10 miles
Do you live near an unemployment office, workforce center or staffing agency? (<2 miles)
*
Yes, one
Yes more than one
The nearest is less than 5 miles away
The nearest is less than 10 miles away
No unemployment office, workforce center or staffing agency is within 10 miles
Do you live near a safe gym, recreation center, or fun hangout spot? (<2 miles)
*
Yes, one
Yes more than one
The nearest is less than 5 miles away
The nearest is less than 10 miles away
No safe gym, recreation center, or fun hangout spot is within 10 miles
Do you get along with everyone in your home? Check the boxes of all the family members you get along with.
*
Mom
Dad
Step parent
Grandparent
Family Gaurdian
Sister
Brother
More than 2 siblings
Friend
Extendend Family Members
Friends
More than 1 Extended Family Members
Do you feel safe at home?
*
Yes
No
Maybe
Not sure?
Do you feel safe in your neighborhood? (<2 mile radius)
*
Yes
No
Maybe
Not sure?
Are you happy with your present home and neighborhood surroundings?
*
Very Happy
Happy
Fairly Happy
Not Particulary Happy
Not Happy at All
Who usually does the cooking (hot food, full meal)?
*
I cook for myself
My partner/cohabitant
Parents/guardians make sure I eat a hot meal everyday
I buy hot food a lot of the times
I mainly snack throughout the day
No real structure I guess, I just eat when I eat
Other
Who usually does the weekly shopping?
*
My partner/cohabitant
Friends, acquaintances, neighbors
Parents/guardians make sure we have groceries throughout the week
I buy groceries a lot of the times
I mainly buy items throughout the day
No real structure I guess, pick up as needed
Other
Who usually does minor repairs (e.g., mending a chair, putting up a hook, changing light bulbs) in your household?
*
I do
My partner/cohabitant
Parents/guardians
Friends, acquaintances, neighbors
Maintenance personnel
Private home help (online, paid service)
Other
Can you count on getting help from others if you become ill, (both from family members and others) and particularly with practical things?
*
Check all that apply
Yes, from someone who lives far away from me
Yes, from someone in the neighborhood
Yes, from the person/people I live with
Yes, from the home help services
No, unfortunatley I have to rely on myself for everything
Im not really sure
Do you feel that you really could do with help from any of the following at the moment?
*
Check all that apply
A physical exam/check up
Therapist
Social worker
Family counselor
Moving out of your environment
Your personal safety
Finding a good job
Furthering your education
Financial literacy
Other
Other Help
*
What is average median income for your home?
*
Please include income of all household members
0- $24,400
$24,400 - $40,650
$40,650 - $62,600
$62,600 - $80,500
$80,500 - $96,600
$96,600 - $118,050
$118,050+
Are you the head of household?
*
Yes
No
The number of persons in the home with disabilites?
*
0
1
2
3
4
5
6
7
8
9
10+
The number of persons in the home over the age of 62?
*
0
1
2
3
4
5
6
7
8
9
10+
The number of full time students in the home over the age of 18?
*
0
1
2
3
4
5
6
7
8
9
10+
The number of children in the home under the age of 18?
*
0
1
2
3
4
5
6
7
8
9
10+
Emergency Contacts
Emergency Contact 1 Name
*
First
Last
Emergency Contact 1 Relationship
*
Emergency Contact 1 Phone
*
Emergency Contact 1 Gender
*
Male
Female
Other
Emergency Contact 1 Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Emergency Contact 2 Name
*
First
Last
Emergency Contact 2 Relationship
*
Emergency Contact 2 Phone
*
Emergency Contact 2 Gender
*
Male
Female
Other
Emergency Contact 2 Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please Accept Our Terms
*
I hereby give my permission for GROW HOME INC and UNITED WAY OF CENTRAL MARYLAND to use without limitation or obligation, photographs and film footage that may include me for the promotion and programs for the sake of increasing capacity for workforce development efforts and greater equity.
I hereby acknowledge that I have carefully read this Waiver and Registration and am aware that in registering myself or my minor child/ward for participation in the program(s), I am waiving and releasing all claims for injuries myself or my child/ward might sustain arising out of the program(s). I recognize and acknowledge that there are certain risks of physical injury to participants in the program(s) and I agree to assume the full risk of any such injuries, damages, or loss regardless of severity which I or my child/ward may sustain as a result of participating in any of the program(s). I hereby fully release and discharge the GROW HOME INC and its officers, agents, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me or my child/ward, and arising out, connected with, or in any way associated with activities of any of the programs.
I, the undersigned participant agree to these terms of program participation and affirm that I am of 18 years of age or older.
I agree
Signature
*
Comments
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