Welcome to ARHA's Family Self-Sufficiency (FSS) Interest/Enrollment Application

IN ORDER TO ENROLL IN FSS YOU MUST ATTEND AN ORIENTATION. FSS ORIENTATION IS EVERY THURSDAY AT 6:00 PM (STARTING MARCH 2, 2017) AT ARHA MAIN OFFICE.

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100% of survey complete.

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* 1. Share with us who you are

Full Name

Address

City, State & Zip

Email Address

Phone #

Are You Currently in the FSS Program?

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* 2. Social Media Handles (Names)

Facebook:

Twitter: @

Other

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* 3. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

Question Title

* 5. Which of the following categories best describes your employment status?

Employed, working 40 or more hours per week

Employed, working 1-39 hours per week

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

Question Title

* 6. How much total combined money did all members of your HOUSEHOLD earn last year?

$0 to $9,999

$10,000 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $124,999

$125,000 to $149,999

$150,000 to $174,999

$175,000 to $199,999

$200,000 and up

Prefer not to answer

Question Title

* 7. Are you currently enrolled as a student?

Yes, full time in graduate school

Yes, part time in graduate school

Yes, full time at a four year undergraduate college/university

Yes, part time at a four year undergraduate college/university

Yes, full time at a two year undergraduate college/university

Yes, part time at a two year undergraduate college/university

Yes, at a high school or equivalent

No, I am not currently enrolled as a student

Question Title

* 8. Choose a goal you would like to work towards:

Education (obtain GED, certification and or degree)

Entrepreneurship (start or grow a small business)

Equity (Purchase your first home)

Employment (increase my earning, get promoted or switch careers)

Other

Question Title

* 9. List CURRENT Skills, trades and or certifications that you possess or will possess soon:

Adminsitrative/ Office Support

Barber/Hair Stylist/Cosmetology License

Bus /Truck Driver

Carpentry

Certified Nurses Assistant (CNA)

Construction

Cooking/Catering Degree or License

CDL (Commercial Driver's License)

Data Entry

Drywall

Electrical

Graphic Artist

Home Health Aide

HVAC

Landscaping

Maintenance

Martial Artist

Masonry

Media Production

Medical Assistant

Military

Nursing

Painting

Plumber

Property Management

Real Estate

Retail

Security Officer

Sports/Recreation

Tattoo Artist

Teacher

Teacher's Aide

Uber

Video Broadcasting

Other (please specify)

Question Title

* 10. How did you hear about FSS?

Walk-In

Referral Specialist (Sabrina Walker)

Case Worker/Occupancy Specialist

Friend

Fliers, email and or posters

Other (please specify)