Today's:date:
*
MM
DD
YYYY
Participant ID#:
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number:
*
(###)
###
####
Email
*
I am interested in help or information about:
*
Don't see what you want? Tell us what you're looking for:
Are you a U.S. Citizen?
*
If you answered No, are you authorized to work in US?
Are you a resident of Wayne County?
*
Are you currently receiving any of the following from the Department of Welfare?
Check all that apply.
Have You received Food Stamps at any time during the past 6-months?
*
Do you receive Supplemental Security Income (SSI):
*
Are you or your child eligible for or receiving free/reduced-price lunch?
*
Under the Richard B. Russell National School Lunch Act.
Are you a High School graduate?
*
If no, what is the highest grade you finished in school?
Have you obtained your GED?
*
Have you attended college or technical school after completing high school?
*
If yes. how many full years did you complete?
Did you obtain a degree?
If yes, what type of degree?
Are you currently working?
*
If yes, name of employer:
Job Title:
If No, name of last employer:
Job Title:
If you are unemployed, please check one box that best describes your reason for layoff:
Unemployment Compensation status:
*
Are you a displaced homemaker?
*
Are you registered with Selective Service (males born after 1/1/1960)
Are you a veteran?
*
Are you a member of the National Reserves?
*
If yes, have you served 180 days or more of active military duty?
Are you the "Spouse of a Veteran?"
Disability Status
*
Have you ever been arrested or convicted of committing a crime (includes misdemeanors)?
*
Do you have a drug or alcohol problem?
*
If yes, are you receiving counseling?
Are you homeless?
*
Are you a single parent?
*
Are you a single pregnant woman?
*
If you are age 24 or under, are you pregnant or the parent of a child who lives with you?
