Fostering Success Registration Form 2020 Survey

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* 1. Contact information

Name *

Address *

Address 2

City/Town *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. County

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* 3. Date of Birth (please use this format 01/01/0000)

Date / Time

Date

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* 4. Age

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* 5. Gender of Applicant

Male

Female

Non-Binary

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* 6. Race

Asian

Black/African American

Native American Pacific Islander

Spanish/Latino/a

White/Caucasian

Other

Decline to Answer

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* 7. Education Level

Senior Year

High School Diploma

GED Certificate

In College

College Graduate

Other (please specify)

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* 8. College Student: Classification (i.e., freshman, sophomore, etc.; leave blank if not a college student)

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* 9. College Student: College Major/Program (leave blank if not a college student)

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* 10. Status

Currently in state's care

Aged out of state's care (at 18 or older)

Adopted (at 14 or older)

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* 11. Living Arrangement

Group home

Foster home

Independent living program

Parents

Project Life

Other (please specify)

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* 12. Primary Transportation

Bus

Own Vehicle

Parent/Caregiver

Other (please specify)

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* 13. Internet Access

Cell phone

Personal computer

Public computer (library, etc.)

None

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* 14. Vital Documents: Do you have a State I.D. or Driver's license?

Yes

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* 15. Vital Documents: Do you have a social security card (Not a copy)?

Yes

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* 16. Vital Documents: Do you have a Birth Certificate (not a copy)?

Yes

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* 17. Do you have prior work experience?

Yes

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* 18. Are you currently employed?

Yes

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* 19. Have you previously participated in Fostering Success?

Yes

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* 20. If yes, what year(s), county(s) and work-site(s)?

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* 21. Career Interest: From the list of career fields below, select your first, second and third choice.

	First Choice	Second Choice	Third Choice
Art, Music, and Entertainment	Art, Music, and Entertainment First Choice	Art, Music, and Entertainment Second Choice	Art, Music, and Entertainment Third Choice
Animal Care	Animal Care First Choice	Animal Care Second Choice	Animal Care Third Choice
Auto Tech	Auto Tech First Choice	Auto Tech Second Choice	Auto Tech Third Choice
Business, Management, and Administration	Business, Management, and Administration First Choice	Business, Management, and Administration Second Choice	Business, Management, and Administration Third Choice
Carpentry	Carpentry First Choice	Carpentry Second Choice	Carpentry Third Choice
Communications (Broadcasting, Journalism, Social Media etc.)	Communications (Broadcasting, Journalism, Social Media etc.) First Choice	Communications (Broadcasting, Journalism, Social Media etc.) Second Choice	Communications (Broadcasting, Journalism, Social Media etc.) Third Choice
Construction and Skilled Trades (Welding, Auto Tech, Carpentry, etc.)	Construction and Skilled Trades (Welding, Auto Tech, Carpentry, etc.) First Choice	Construction and Skilled Trades (Welding, Auto Tech, Carpentry, etc.) Second Choice	Construction and Skilled Trades (Welding, Auto Tech, Carpentry, etc.) Third Choice
Criminal Justice, Law Enforcement, and First Responders	Criminal Justice, Law Enforcement, and First Responders First Choice	Criminal Justice, Law Enforcement, and First Responders Second Choice	Criminal Justice, Law Enforcement, and First Responders Third Choice
Culinary Arts (Food Service and Restaurants)	Culinary Arts (Food Service and Restaurants) First Choice	Culinary Arts (Food Service and Restaurants) Second Choice	Culinary Arts (Food Service and Restaurants) Third Choice
Education	Education First Choice	Education Second Choice	Education Third Choice
Child Care	Child Care First Choice	Child Care Second Choice	Child Care Third Choice
Engineering and Technical Sciences	Engineering and Technical Sciences First Choice	Engineering and Technical Sciences Second Choice	Engineering and Technical Sciences Third Choice
Entrepreneur	Entrepreneur First Choice	Entrepreneur Second Choice	Entrepreneur Third Choice
Farming, Gardening and Natural Resources	Farming, Gardening and Natural Resources First Choice	Farming, Gardening and Natural Resources Second Choice	Farming, Gardening and Natural Resources Third Choice
Finance, Insurance and Banking	Finance, Insurance and Banking First Choice	Finance, Insurance and Banking Second Choice	Finance, Insurance and Banking Third Choice
Government and Public Service	Government and Public Service First Choice	Government and Public Service Second Choice	Government and Public Service Third Choice
Health and Medical Services	Health and Medical Services First Choice	Health and Medical Services Second Choice	Health and Medical Services Third Choice
Hotels and Special Attractions	Hotels and Special Attractions First Choice	Hotels and Special Attractions Second Choice	Hotels and Special Attractions Third Choice
Human Resources	Human Resources First Choice	Human Resources Second Choice	Human Resources Third Choice
Information Technology	Information Technology First Choice	Information Technology Second Choice	Information Technology Third Choice
Law	Law First Choice	Law Second Choice	Law Third Choice
Manufacturing (Ford, GE Appliances, etc.)	Manufacturing (Ford, GE Appliances, etc.) First Choice	Manufacturing (Ford, GE Appliances, etc.) Second Choice	Manufacturing (Ford, GE Appliances, etc.) Third Choice
Medical Services	Medical Services First Choice	Medical Services Second Choice	Medical Services Third Choice
Patient Care	Patient Care First Choice	Patient Care Second Choice	Patient Care Third Choice
Real Estate, Rentals, and Leasing	Real Estate, Rentals, and Leasing First Choice	Real Estate, Rentals, and Leasing Second Choice	Real Estate, Rentals, and Leasing Third Choice
Retail Trade and Customer Service	Retail Trade and Customer Service First Choice	Retail Trade and Customer Service Second Choice	Retail Trade and Customer Service Third Choice

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* 22. Are you interested in completing a vocational or trade program this summer?

Yes

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* 23. If yes, choose areas that may be of interest to you (please select all that apply):

Manufacturing (such as Welding, Maintenance Mechanic, Machine Tool Operator, Machinist, etc.)

Business & IT Service (such as Web Programming, Payroll Accounting, etc.)

Construction (such as Heating and Air Conditioner, Electrician, Rough Carpentry, Plumber, etc.)

Healthcare (such as Ultrasound Technician, Paramedic, Fire/Rescue, Radiography, Respiratory Therapist,
Medical Coding, Phlebotomist, C.N.A., etc.)

Automotive (such as Brakes Technician, Tune-Up Mechanic, Auto Painter, Auto Transmission Technician, etc.)

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* 24. Is there a specific company or type of organization that you would like to work for this summer? Example: Department for Community Based Services, Parks and Recreation, Kroger’s, housekeeping, administrative, factory, hospital, warehouse etc.

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* 25. Please describe your ideal career:

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* 26. Do you have transportation challenges?*
* Please note this question is optional. You are not required to disclose the information in this section but doing so will help us in assisting you with barriers to your successful completion of the program and ensuring you are connected to the necessary community resources.

I need to work on the bus line

My city doesn’t have public transportation and I don’t have a car

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* 27. Do you face any of the challenges below? Select all that apply:
Please note this question is optional. You are not required to disclose the information in this section but doing so will help us in assisting you with barriers to your successful completion of the program and ensuring you are connected to the necessary community resources.

English is not my primary language.

I have a physical, mental, learning, or other disability.

I have a criminal record that may affect my employment.

I use substances that may affect my employment.

I am parenting and need childcare.

I am currently homeless.

Other needs or concerns (please specify):

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* 28. Emergency Contact

Name

Email Address

Phone Number

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* 29. Is this phone number a cell, home, or work number?

Cell

Home

Work

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* 30. What is your relationship to the emergency contact?

Parent

Social Worker

Case Worker

Other (please specify)

Fostering Success Registration Form 2020

Applicant Information

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* 1. Contact information

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* 2. County

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* 3. Date of Birth (please use this format 01/01/0000)

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* 4. Age

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* 5. Gender of Applicant

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* 6. Race

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* 7. Education Level

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* 8. College Student: Classification (i.e., freshman, sophomore, etc.; leave blank if not a college student)

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* 9. College Student: College Major/Program (leave blank if not a college student)

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* 10. Status

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* 11. Living Arrangement

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* 12. Primary Transportation

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* 13. Internet Access

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* 14. Vital Documents: Do you have a State I.D. or Driver's license?

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* 15. Vital Documents: Do you have a social security card (Not a copy)?

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* 16. Vital Documents: Do you have a Birth Certificate (not a copy)?

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* 17. Do you have prior work experience?

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* 18. Are you currently employed?

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* 19. Have you previously participated in Fostering Success?

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* 20. If yes, what year(s), county(s) and work-site(s)?

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* 21. Career Interest: From the list of career fields below, select your first, second and third choice.

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* 22. Are you interested in completing a vocational or trade program this summer?

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* 23. If yes, choose areas that may be of interest to you (please select all that apply):

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* 24. Is there a specific company or type of organization that you would like to work for this summer? Example: Department for Community Based Services, Parks and Recreation, Kroger’s, housekeeping, administrative, factory, hospital, warehouse etc.

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* 25. Please describe your ideal career:

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* 28. Emergency Contact

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* 29. Is this phone number a cell, home, or work number?

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* 30. What is your relationship to the emergency contact?