Student Intake Form

Please fill out the form completely, reading the narrative sections carefully. 

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* 1. Welcome to the EmPower Program

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* 2. What is your name?

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* 3. What is your personal email address?

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* 4. What are your current address?

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* 5. Who is your DHS Case Worker? What is your Case Number?

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* 6. Emergency Contact - What is their first and last name? What is their phone number?

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* 7. Which category below includes your age?

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* 8. What is the highest level of school you have completed or the highest degree you have received?

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* 9. Which of the following categories best describes your most recent employment status?

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* 10. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

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* 11. How many children, by age, currently live in your household?

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* 12. Have you ever served in any branch of the United States military, or not?

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* 13. Are you currently enrolled as a student?

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* 14. What ONE word do you think best describes me?

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* 15. Do you currently receive child support, or not?

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* 16. Do you have any legal obstacle?

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* 17. Do you have a history of drug use?

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* 18. Are you a registered voter?

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* 19. Acknowledgements and Permissions

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* 20. If you could have any superpower, which would it be?

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