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* 1. Please enter your full name:

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* 2. Current address:

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* 3. Preferred phone number:

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* 4. Alternate phone number:

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* 5. Email address:

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* 6. Birthdate:

Date

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* 7. Marital status

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* 8. Number of children:

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* 9. Names and birthdates of children:

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* 10. What level of education have you COMPLETED?

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* 11. Please list the places you have worked in the last three years:

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* 12. Do you have a Facebook account

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* 13. What is your Facebook name?

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* 14. Childcare of some sort is essential when working.  Please list the childcare options that work best for you.

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* 15. I am interested in short-term, one time work opportunities that pop up through the JOBS program.

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

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* 17. Do you have a car to use to get to work?

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* 18. Do you currently have automobile liability insurance?

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* 19. If you could choose your occupation, what would you choose?

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* 20. Practically speaking, I see myself working at....

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* 21. What government assistance are you currently receiving?  Check ALL that apply.

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* 22. Please list the current members of your household:

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* 23. Do other members of your household contribute financially or do you receive child support?

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* 24. JOBS is a mentoring program.  You will be assigned a mentor to help you with goal setting, training, and obtaining/keeping a job.  Do you agree to work with a mentor?

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* 25. Employers look at Facebook pages.  I agree to have a Facebook page that is presentable to employers, and am open to suggestions from my mentor.

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* 26. Part of the JOBS program is working through financial goals.  Do you agree to work with your mentor or with the Financial Empowerment Center in budgeting and goal setting?

Thank you for completing this survey!  You will be hearing from us soon.  We look forward to working together!  Any questions can be submitted to jumponboardforsuccess@gmail.com.
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