Client Applications Name Today's Date Address Apt # City/State/Zip CHA Recipient Yes No Home Tel. # Cellular Emergency Contact Name Emergency Contact # Race SSN (last 4) # Date of Birth Gender Male Female Other City Ward Children Yes No Case Number Name of High School/GED Diploma Yes No Name of Trade, Busines or Correspondence School Area of Study Certificate or Diploma Yes No Name of University Area of Study Degree Yes No 1.Employer Job Title Address Duties City/State Start Date End Date Reason for Leaving 2.Employer Job Title Address Duties City/State Start Date End Date Reason for Leaving 3.Employer Job Title Address Duties City/State Start Date End Date Reason for Leaving What personal skills do you have that might help us find you a job? Check all that apply Evaluator Anticipator Goal-Oriented Negotiator Flexible Other Detailed Innovator Performance Driven Clean Planner Other Builder Communicator Public Speaker Supportive Counsel Other Budgeter Typist Stand for Hours Persuasive Supervisor Other Barter Coordinator Creative Writer Researcher Other Analyzer Assembler Environmentally Adapt Organized Managing Other Adviser Initiator Patient Attentive Teacher Other Adapter Scheduler Machine Operator Punctual Driver Other Do you need child care assistance to begin this program? Yes No Do you have drug or alcohol problem? Yes No Do you need assistance in dealing with domestic violence? Yes No Are you homeless? Do you need housing assistance? Yes No Are you a veteran? Yes No Do you have a valid driving license? Yes No Is someone helping you to fill out this application? Yes No Are you an Ex-Offender? Yes No Are you in need of any special services or have any other problems? Yes No If yes, please list List three jobs you qualified for: List three training classes that would help you qualify for the jobs you chose: Would you be willing to take a volunteer work assignment without pay to help you get work experience? Yes No Date You must complete this form, and return it to CAPs staff before leaving orientation session. This form verifies your participation in Orientation. If you do not complete and return this form, you will be required to take this session again. Date Location Program My name is Phone My plans for future: I want CAPs to help me: The Orientation Session was? Well Informative Answered my questions Well Presented Was OK Was Bad To make this Orientation better I suggest: Check only those that apply and you must sign and date: Yes, I received SNAP program brochure, (if no, please request one now) Yes, I received SCSEP Participant Handbook (if applying for the 55+ program) I have also received information regarding the IETC One Stop, Job search and resource labs to further help me obtain employment. I understand as a TANF recipient I will be assigned and must complete 30 hours per week to be eligible for TANF benefits. Signature Send
