JOBS Participant Application

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* 1. Did an agency or organization refer you? If yes, please list who. If no, please let us know how you heard about JOBS.

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* 2. Full Name and 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

Single, never married

Single, divorced

Married

Married, but separated

Just living together

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* 8. Number of children:

one

two

three

four

five

six or more

None

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* 9. Names and birthdates of children:

Child one

Child two

Child three

Child four

Child five

Child six

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* 10. What level of education have you COMPLETED?

9th grade

10th grade

11th grade

12th grade

Graduated high school

Obtained GED

Some college

Graduated college 2 year degree

Graduated college 4 year degree

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

Current Employer

Other

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* 12. Do you have a Facebook account

Yes

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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.

Child's father can watch while I work

I have a family member that can help

I have friends that help with childcare

I use Title 20 for childcare and am already registered

I will need to sign up for Title 20 (government assisted) childcare

I have no clue

I private pay for childcare

Other (please specify)

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

Yes

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

Yes

I have a valid temporary license

I need to take the temp's test

I need help working through this whole process

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

Yes, I have my own car

I borrow a family member's car

Someone else drives me to work

I ride the bus

I need help figuring this out

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* 18. Do you currently have automobile liability insurance?

Don't need it, I don't have a car

I have a car, but not coverage

I had coverage, but it lapsed

I carry a bond instead

Yes, I have coverage!

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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.

Medical insurance for myself

Medical insurance for my children

Groceries

Housing

PIP

Section 8 voucher

Cash assistance

Other (please specify)

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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?

Household member contributes financially

I receive child support on a regular basis

I am supposed to receive child support, but it is not regular

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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?

Yes

Other (please specify)

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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.

Yes, absolutely, I want my Facebook page to be good for employers who see it

I don't have a Facebook page

I am a little hesitant on this one, so I'm not sure yet

I really don't want to change my Facebook page or posts

I will have an alternate facebook account that isn't visible to the general public

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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?

Yes

Other (please specify)

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.