Harmony Career Network - H.E.L.P.ENROLLMENT APPLICATION Survey

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* 2. Applicant’s Name (last, first):

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* 3. Social Security Number:

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* 4. Date of Birth:

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* 5. Age:

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* 6. Gender:

Male

Female

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* 7. Marital Status:

Married

Separated

Widowed

Divorced

Single

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* 8. Ethnicity

African American

White

Asian

American Indian

Hispanic

Other

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* 9. Where/with whom do you reside?

Spouse

Parent

Family Members

Friend

Self

Other (please specify)

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* 10. Are you a live-in Caregiver?

Yes

If yes, to whom?

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* 11. Address:

City, State:

Zip:

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* 12. Is this a permanent or temporary address?

Yes

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* 13. How can you be contacted?

Phone Number:

Alternative Number:

Email Address:

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* 14. If homeless, do you have a case manager or someone working with you?

Yes or No?

When was the last time you had a permanent address?

If homeless, what were the circum- stances of your homelessness?

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* 15. In your current residence, do you have a working refrigerator?

Yes

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* 16. In your current residence, do you have a working means for cooking?

Yes

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* 17. Do you have children/grandchildren under age 18 living with you?

Yes

If yes, how many?

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* 18. What are their ages?

1st Child

2nd Child

3rd Child

4th Child

5th Child

6th Child

7th Child

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* 19. Do you have adequate Child Care?

Yes

Do children need tutoring? Yes or no?

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* 20. What are the 3-4 most important concerns in your life, ex: Employment, Health, Food, Paying Bills, Domestic Violence, etc.?

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* 21. Any unpaid Pay Day Loans?

Yes

Your approximate monthly expenses?

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* 22. How did you hear about Harmony Food Pantry?

NT Food Bank

Friend/Word of Mouth

Concord Church Member

Other

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* 23. How long have you been coming to Harmony Food Pantry?

1-6 months

7-12 months

More than 1 year

1.5 to 2 years

More than 2 years

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* 24. Do you attend church?

Yes

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* 25. If yes, to the previous questions, how often?

Almost every week

Once or twice a month

Every couple of months

Once or twice a year

Harmony Career Network - H.E.L.P.ENROLLMENT APPLICATION

Part I: Personal Background

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* 1. Date:

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* 2. Applicant’s Name (last, first):

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* 3. Social Security Number:

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* 4. Date of Birth:

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* 5. Age:

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* 6. Gender:

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* 7. Marital Status:

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* 8. Ethnicity

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* 9. Where/with whom do you reside?

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* 10. Are you a live-in Caregiver?

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* 11. Address:

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* 12. Is this a permanent or temporary address?

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* 13. How can you be contacted?

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* 14. If homeless, do you have a case manager or someone working with you?

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* 15. In your current residence, do you have a working refrigerator?

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* 16. In your current residence, do you have a working means for cooking?

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* 17. Do you have children/grandchildren under age 18 living with you?

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* 18. What are their ages?

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* 19. Do you have adequate Child Care?

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* 20. What are the 3-4 most important concerns in your life, ex: Employment, Health, Food, Paying Bills, Domestic Violence, etc.?

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* 21. Any unpaid Pay Day Loans?

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* 22. How did you hear about Harmony Food Pantry?

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* 23. How long have you been coming to Harmony Food Pantry?

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* 24. Do you attend church?

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* 25. If yes, to the previous questions, how often?

Harmony Career Network - H.E.L.P.
ENROLLMENT APPLICATION