Employment Contact Registration Form 50% of survey complete. Question Title * 1. Last name (Required.) Question Title * 2. First Name (Required.) Question Title * 3. Sex (Required.) Male Female Question Title * 4. Address: (Required.) Street Address Apt City State Zip Code Question Title * 5. Phone Number: (Required.) Home Work Mobile Question Title * 6. Email Address: Primary Email Secondary Email Question Title * 7. Emergency Contact Information: (Required.) Name Number Relationship Question Title * 8. Marital Status: (Required.) Single Married Divorced Separated Widowed Question Title * 9. Food Stamp recipient: (Required.) Yes No Question Title * 10. Are you raising children? (Required.) Yes No Question Title * 11. Is childcare in place? (Required.) Yes N/A Question Title * 12. Are you under 21 yrs? (Required.) Yes No Question Title * 13. Do you live in? (Required.) Rented Apt. Own Home/Condo Shelter/Halfway House Homeless Question Title * 14. RACE / ETHNICITY (Required.) African American / Black American Indian / Native Alaskan Asia / Pacific Islander Hispanic / Latino White / Caucasian Other (SPECIFY) Question Title * 15. Are you bilingual? (Required.) Spoken Read Write Yes Yes Spoken Yes Read Yes Write No No Spoken No Read No Write If yes, indicate what languages you are fluent in Question Title * 16. Highest grade completed (K-12)? (Required.) Question Title * 17. Highest education attained? (Required.) H.S. Diploma GED Associate Degree Bachelor Degree Master Degree Advanced Degree None Question Title * 18. Are you registered to vote? (Required.) Yes No Question Title * 19. If you have a degree, indicate major Question Title * 20. Were you educated in the U.S.? (Required.) Yes No If no, what country were you educated in? Question Title * 21. Are you currently employed? (Required.) Yes No If no, indicate date last worked (MM/YY) Question Title * 22. If yes, indicate # of hours you work and check status? (Required.) Contract Full Time Part Time Per Diem Self-employed # of hours worked Question Title * 23. Are you registered with a Workforce1 Center? (Required.) Yes No If yes, which location are you registered with? Question Title * 24. How did you hear about the NEW YORK URBAN LEAGUE? (Please check all that apply) (Required.) Friends / Relative Walk In Internet / Email Media (News / Radio?TV) Flyer NYUL program Referred by another program Elected official Other Other (please specify) Question Title * 25. Do you have access to a computer? (Required.) Home Library Cell Phone Yes Yes Home Yes Library Yes Cell Phone No No Home No Library No Cell Phone Other (please speficy) Next