Revolution Workshop Training Application Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Date Date / Time Date Time AM/PM - AM PM Question Title * 4. Social Security Number Question Title * 5. Date of Birth Birthdate Date Question Title * 6. Address Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 7. Preferred method of contact Cell Phone Call Cell Phone Text Email Question Title * 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 Question Title * 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 Question Title * 10. Gender: How do you identify? Female Male Non-binary Prefer not to answer Self-describe Question Title * 11. Marital Status Single Married Divorced Question Title * 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) Question Title * 13. Primary Language English Spanish Polish Arabic Other (please specify) Question Title * 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 Question Title * 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) Question Title * 16. Total number of adults in your household Question Title * 17. Total number of children in your household Question Title * 18. Are you the head of your household? Yes No Question Title * 19. Do you have children not in your household that you provide child care or support for? Yes No Question Title * 20. If yes, how many children? Question Title * 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 Question Title * 22. How many people in your household work? Question Title * 23. How many months have you personally worked in the past 12 months? Question Title * 24. What was your income for the past 12 months after taxes (estimate)? Question Title * 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) Question Title * 26. Have you ever collected unemployment benefits? Yes No Question Title * 27. If yes, when was the last time? Question Title * 28. How will you financially support yourself during training? Question Title * 29. Do you have a dependable car? Yes No Question Title * 30. Do you have a valid driver's license? Yes No Question Title * 31. If no, how will you get to training? Question Title * 32. If you have children that need childcare, how will this be provided? Question Title * 33. Do you currently have health insurance? Yes No Question Title * 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 Question Title * 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: Question Title * 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 Question Title * 37. If male and born after December 31, 1959, have you registered for the selective service? Yes No Question Title * 38. Have you ever served in the military? Yes No Question Title * 39. Have you ever been convicted of a felony? Yes No Question Title * 40. If yes, nature of felony offense/s: Question Title * 41. Years of felony conviction Question Title * 42. Were you incarcerated due to your felony conviction? Yes No Other (please specify) Question Title * 43. Have you ever been convicted of a misdemeanor? Yes No Question Title * 44. If yes, nature of misdemeanor offense/s: Question Title * 45. Years of misdemeanor convictions Question Title * 46. Do you have any pending cases/charges? Yes No Question Title * 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: Question Title * 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) Question Title * 49. If yes, what is your hourly wage? Question Title * 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? Question Title * 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. Question Title * 52. What abilities and strong points do you have that will help you succeed in this training? Question Title * 53. List at least two references. Include name, phone number, email, and circumstances of your acquaintance. Exclude relatives. Question Title * 54. Which virtual information session did you attend? Tues. Feb 22nd Thurs. Feb. 24th Tues. March 1st Thurs. March 3rd Tues. March 8th Thurs. March 10th Tues. March 15th Thurs. March 17th Tues. March 22nd Thurs. March 24th Tues. March 29th Thurs. March 31st Tues. April 5th Thurs. April 7th Tues. April 12th Thurs. April 14th Tues. April 19th Thurs. April 21st Tues. April 26th Thurs. April 28th Tues. May 3rd Thurs. May 5th OTHER - Please indicate which non-weekly info session presentation you attended. Done