Revolution Workshop Training Application Survey

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* 3. Date

Date / Time

Date

Time

AM/PM

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* 4. Social Security Number

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* 5. Date of Birth

Birthdate

Date

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* 6. Address

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 7. Preferred method of contact

Cell Phone Call

Cell Phone Text

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* 8. How did you hear about the program?

Social Media

Another Program/Organization (if so, which organization?)

Family/Friend/Word of Mouth

Graduate of the Program (if so, who was it?)

Group Presentation (if so, where was it?)

Other

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* 9. Which of our training sites would you prefer to enroll in?

Garfield Park - 3410 W Lake St.

Pullman - 11314 S Front Ave.

No preference

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* 10. Gender: How do you identify?

Female

Male

Non-binary

Prefer not to answer

Self-describe

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* 11. Marital Status

Single

Married

Divorced

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* 12. How do you describe your race/ethnicity?

Black or African American

Hispanic or Latinx

White or Caucasian

Asian or Asian American

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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* 13. Primary Language

English

Spanish

Polish

Arabic

Other (please specify)

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* 14. Please identify your living arrangements

House/ Apartment is owned by household member

House/ Apartment is rented by household member and is NOT subsidized

House/ Apartment is rented by household member and IS subsidized

You are without a home

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* 15. If you are without a home, please identify your housing arrangements:

Living in a shelter

Staying with a friend or relative

Staying at a Halfway House/Transitional Housing

Other (please specify)

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* 16. Total number of adults in your household

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* 17. Total number of children in your household

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* 18. Are you the head of your household?

Yes

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* 19. Do you have children not in your household that you provide child care or support for?

Yes

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* 20. If yes, how many children?

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* 21. Please List all members in your household with the following information: their name, relationship to you, date of birth, if they are your dependent, and if they have income

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* 22. How many people in your household work?

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* 23. How many months have you personally worked in the past 12 months?

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* 24. What was your income for the past 12 months after taxes (estimate)?

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* 25. Please check any income that apply to your household:

Employment

SNAP (Food Stamps)

Unemployment

TANF

Child Support

Supplemental Security Income

Social Security Disability Income

Social Security Pension

Other (please specify)

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* 26. Have you ever collected unemployment benefits?

Yes

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* 27. If yes, when was the last time?

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* 28. How will you financially support yourself during training?

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* 29. Do you have a dependable car?

Yes

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* 30. Do you have a valid driver's license?

Yes

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* 31. If no, how will you get to training?

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* 32. If you have children that need childcare, how will this be provided?

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* 33. Do you currently have health insurance?

Yes

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* 34. If yes, what type of health insurance?

Public Health Insurance (Medicare, Medicaid, etc.)

Private Health Insurance (Through a household member’s employer)

Private Health Insurance (NOT through a household member’s employer)

Not Applicable

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* 35. What is the highest level of education you have completed?

No high school diploma/equivalency

High School Diploma

GED

Some College

Associates Degree

Bachelor's Degree

Master's Degree

Doctoral Degree

Job Training Program:

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* 36. Are you a U.S. Citizen?

Yes, I can provide proof that I am a U.S. Citizen

No, but I can provide authorization to work in the United States

No, neither of the above

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* 37. If male and born after December 31, 1959, have you registered for the selective service?

Yes

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* 38. Have you ever served in the military?

Yes

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* 39. Have you ever been convicted of a felony?

Yes

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* 40. If yes, nature of felony offense/s:

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* 41. Years of felony conviction

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* 42. Were you incarcerated due to your felony conviction?

Yes

Other (please specify)

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* 43. Have you ever been convicted of a misdemeanor?

Yes

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* 44. If yes, nature of misdemeanor offense/s:

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* 45. Years of misdemeanor convictions

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* 46. Do you have any pending cases/charges?

Yes

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* 47. Do you have any reason/s why you might need to miss class during the program such as court dates, doctor appointments, counseling, travel, etc. Please specify dates and reason:

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* 48. Are you currently employed?

Yes, Full-Time

Yes, Part-Time

No, laid off due to company closure, downsizing, etc.

No, Quit

No, terminated/fired

Other (please specify)

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* 49. If yes, what is your hourly wage?

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* 50. Please list your most recent work history with the following information: Name of employer, address, job title, month/year start, pay rate, month/year end date, number of hours per week, skills learned, why did you leave?

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* 51. Describe any additional skills, talents, or hobbies you have. For example, do you work on cars, sew, repair small appliances, fix plumbing, or play a musical instrument? Please be specific.

Revolution Workshop Training Application

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* 1. First Name

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* 2. Last Name

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* 3. Date

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* 4. Social Security Number

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* 5. Date of Birth

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* 6. Address

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* 7. Preferred method of contact

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* 8. How did you hear about the program?

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* 9. Which of our training sites would you prefer to enroll in?

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* 10. Gender: How do you identify?

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* 11. Marital Status

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* 12. How do you describe your race/ethnicity?

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* 13. Primary Language

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* 14. Please identify your living arrangements

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* 15. If you are without a home, please identify your housing arrangements:

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* 16. Total number of adults in your household

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* 17. Total number of children in your household

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* 18. Are you the head of your household?

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* 19. Do you have children not in your household that you provide child care or support for?

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* 20. If yes, how many children?

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* 21. Please List all members in your household with the following information: their name, relationship to you, date of birth, if they are your dependent, and if they have income

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* 22. How many people in your household work?

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* 23. How many months have you personally worked in the past 12 months?

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* 24. What was your income for the past 12 months after taxes (estimate)?

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* 25. Please check any income that apply to your household:

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* 26. Have you ever collected unemployment benefits?

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* 27. If yes, when was the last time?

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* 28. How will you financially support yourself during training?

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* 29. Do you have a dependable car?

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* 30. Do you have a valid driver's license?

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* 31. If no, how will you get to training?

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* 32. If you have children that need childcare, how will this be provided?

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* 33. Do you currently have health insurance?

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* 34. If yes, what type of health insurance?

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* 35. What is the highest level of education you have completed?

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* 36. Are you a U.S. Citizen?

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* 37. If male and born after December 31, 1959, have you registered for the selective service?

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* 38. Have you ever served in the military?

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* 39. Have you ever been convicted of a felony?

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