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Last Name
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Email Address
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Phone Number
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Postal Code
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SSN #
Housing Needs
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Do you have secure housing?
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Do you own your home?
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Do you rent?
Yes
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Are you living at a shelter?
Yes
No
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Please specify which shelter.
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Are you staying temporarily with a friend or family member?
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Transportation Needs
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Do you have reliable transportation?
Yes
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How will you be getting to work?
Bus
Personal Vehicle
Ride Sharing
Friend or Family
Food Needs
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Do you have access to meals on a regular basis?
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How do you get your meals?
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Are you connected with a local organization to help with healthy food options?
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Education Needs
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What is your highest level of education?
(This will NOT hurt your application. This will help with what training we provide for you.)
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None
Primary Education
High School
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Is there anything you feel you need trained in/gain more skills on?
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Childcare Needs
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Do you have children?
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Do you have before or after school care during the school year?
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Do you have summer childcare?
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Communication Needs
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Do you have access to a phone?
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Is it your phone or do you share one?
What is the best way to reach you?
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Do you have a voicemail set up?
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Do you have a computer or iPad?
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