1.What is your first and last name?

2.What is your email?

3.What is your phone number?

*4.Do you or anyone in your family receive one of the following state or federal government assistance?

• Employment Related Day Care (ERDC)
• Food Distribution Program on Indian Reservations (FDPIR)
• Housing Choice Vouchers (Section 8)
• Oregon Health Plan (OHP)
• Social Security Disability Insurance (SSDI)
• Supplemental Nutrition Assistance Program (SNAP)
• Supplemental Security Income
• Temporary Assistance for Needy Families (TANF)
• Women, Infant, Children (WIC)

If yes, proof of Government Assistance will need to be shown when you come in for training.(Required.)

Yes

No