Resident Intake Form - WCC Employment Research Study

Welcome!

The following form is to register for the Working Communities Challenge Employment Research Study. This study is only available to residents of SAWCC Region (Southern Windsor and Northern Windham counties in Vermont).

Please fill out the information below accurately. The information is needed to provide the $40 survey incentive. All responses for the surveys will be anonymous. Participant information will not be used for any other purpose beyond notification to complete a survey and receiving the incentive.

Please contact Amanda Porter, WCC Coordinator, with any questions.

amanda@springfielddevelopment.org

802-885-3061

Question Title

* 1. Please enter the information below.

Participant Full Name

Primary Email Address

Secondary Email Address

Primary Phone Number

Secondary Phone Number

Mailing Address (street #/P.O.Box #)

Town

Zip Code

State

Question Title

* 2. How old are you?

Question Title

* 3. What is your current housing status?

I own my home

I rent my home

I live with relatives/friends (not renting)

I currently do not have housing/ not applicable

Other (please specify)

Question Title

* 4. What is your average monthly income?

Less than $1,000

$1,000- $2,000

$2,000- $3,000

$3,000- $4,000

$4,000- $5,000

More than $5,000