Name of Individual Completing Form(Required) First Last Name of Organization(Required) Enrollment Date:(Required) MM slash DD slash YYYY Applicant Name(Required) First Middle Last Social Security Number(Required) CONTACT INFORMATIONAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberPhone TypeMobileHomeWorkOtherAlternate PhonePhone TypeMobileHomeWorkOtherEmail Mailing Address Mailing address is different from above.Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DEMOGRAPHIC INFORMATIONDate of Birth(Required) Month Day Year Gender(Required)FemaleMaleNonbinaryTransgender/Gender NoncomformingPrefer to not self-identifySexual Orientation(Required)HeterosexualGayLesbianBisexualAsexualQueerOtherPrefer to not self-identifyDo you have a disability?(Required) Yes No Are you a Veteran?(Required) Yes No Authorization to Work in US(Required)Citizen of U.S.Alien/Refugee Lawfully Admitted to U.S.U.S. Permanent ResidentNoImmigrant(Required) Yes No Ethnicity(Required)WhiteBlack/African AmericanAmerican Indian/Alaskan NativeHispanic/LatinMiddle Eastern or North AfricanNative HawaiianPacific IslanderAsianChoose Not to RespondOther Ethnicity not on the listIf identifying as Asian, pleas check all that apply. Indian Pakistani Bangladesh Sri Lankan Nepalese Sikkimese Bhutanese Japanese Chinese Korean Malaysian Thai Laotian Cambodian Vietnamese Filipino Other Asian If identifying as Pacific Islander, please check all that apply, Samoan Palauan Micronesian Guamanian Marshallese Other Pacific Islander Please state your language of preference, if other than English. EDUCATIONCurrently in School:(Required) Yes No Highest Level of Education Completed(Required)No HS Diploma or EquivalentHS Diploma or EquivalentSome postsecondary educationPostsecondary certification (non-degree)Associate's DegreeBachelor's DegreeGraduate DegreeINCOMEAnnual Individual Income:(Required) Household Size:(Required) Annual Household Income:(Required) EMPLOYMENT INFORMATIONPlease select the option below that describes your employment status:(Required)EmployedUnderemployed (working part-time & want full-time work or working below education or skill level)Not in Labor Force (not employed and not actively looking for work, including currently incarcerated)Unemployed (not employed, but seeking work)Are you a Dislocated Worker (has been terminated or laid off and is eligible for Unemployment Insurance (UI) benefits)? Yes No If unemployed, approximately how many weeks?(Required) Long Term unemployed (has been unemployed for 27 consecutive weeks or more):(Required) Yes No ADDITIONAL INFORMATION The following information is gathered only to provide aggregate information on populations served through state funded grants and to identify additional supports needed. Answers in this section do not impact enrollment decisions.Please check if you identify with any of the circumstances listed. Identification may qualify you for more services.(Required) Receiving Public Benefits Foster Care Individual (has ever been in a foster care system) Unhoused Individual or Runaway Youth Formerly Incarcerated/Justice Involved (has been subject to any stage of the criminal justice process, or requires assistance resulting from a record or arrest or conviction) English Language Learner (has limited ability with the English language and whose native language is other than English or is in a family or community environment where English is not the dominant language) Basic Skills/Low Literacy Learner (unable to compute and solve problems, or read, write, or speak English at a level necessary to function on the job, in the participant’s family, or in society) Single Parent (a single individual who has primary responsibility for one or more dependent children under the age of 18) If receiving public benefits, please check all that apply(Required) TANF Recipient Exhausted TANF (i.e. CalWORKs) Eligibility Food Stamps (i.e. CalFRESH) Eligibility SSI/SSDI Recipient Not Applicable DESIRED EMPLOYMENTDesired Occupation:(Required) Desired Industry:(Required) CAPTCHA
