PERSONAL DATA:
Name:
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Email Address:
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Last Four of Social Security Number:
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Address:
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Phone Number:
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Emergency Contact Name:
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Relationship:
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Emergency Contact Phone:
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Age:
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Date of Birth:
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INCOME - Current Source(s) of income (check all that apply):
Work (full-time)
Work (part-Time)
TANF
LINK
SSI/SS
Child Support
Earned Income Tax Credit
Township
Medical Card
SERVICES - Please check any of the following services/resources you are/have used:
WIC
Well Baby
DCFS
Treatment Program
FHN Family Counseling
Stephenson Co. Health Dept.
IL Dept of Human Services
RAMP
VOICES
Other (explain Below)
Other Explanation:
Do you have a case worker that helps you/family find the services you need?:
Yes
No
If yes, person's name and agency name:
TRANSPORTATION:
Do you::
Own Car
Ride with family/friends
Use local public transportation
Do you have a valid driver's license?:
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==Please select==
Yes
No
EDUCATION & EMPLOYMENT:
Highest Level of Education Completed:
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==Please select==
9th
10th
11th
High School Diploma
G.E.D.
Some College (no degree)
Associates Degree
Bachelors Degree
Masters Degree
Certifications (please list):
List your last three places of employment. Begin with your current or most recent job.:
TRAINING:
I am interested in being trained in a carrier as:
Administrative Assistant
Child Development
Construction
Paramedic (EMT)
Housekeeping
Culinary / Food Service
Paralegal
Pharmacy Tech
insurance Industry
Truck Driving
Computer Programmer
Electronics
Customer Service Rep
Factory
Child Care
Elder Care
Court Reporter
Phlebotomist
X-Ray Tech
Automotive Technology
Teacher / Teacher Assistant
Cosmetology
RN/LPN/CAN
Retail Sales Associate
Hospitality (Hotel/Motel)
Social Services
Prison/Jail Guard
Lab Tech
Physical Therapy
Landscape / Lawn Maint.
Other (Explain Below)
Other Explain:
I would be interested in attending workshops on the following topics:
Communication Skills
Organization Skills
Stress Management
Time Management
Resume Writing/Interviews
Parenting Skills
Money Management
Home Ownership
Credit Building / Repair
Other (Explain Below)
What would be good days and times for you to attend a workshop?:
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
HOUSEHOLD:
List all people living in the household (Name, Relationship, Date of Birth):
List children receiving childcare or who will need child care if you become employed:
As an FSS Participant, what support services would you need?:
Counseling
Medical Care Assistance
Job Training/Placement
Nutrition
Child Care
Job Placement
Domestic Violence
Transportation
Career Counseling
Budgeting
Education / G.E.D. Asst
Job Retention
Credit
Reading Skills
Parenting Invormation
Drug/Alcohol Counseling
Math Skills
Other (explain Below)
Where do you see yourself and your family in 5 years?:
What are your greatest concerns/needs for yourself and your family in meeting your goals?:
I need the following questions answered about Family self Sufficiency:
PLEASE READ BELOW:
I hereby certify under penalies of perjury that the above statements are true and correct. I understand that the City of Freeport Housing Authority will verify the statements herein, and I have no objections to inquiries being made.
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any department or agency of the U.S. as to any matter within its jurisdictions.
Please type your name if you understand the above statement:
*
Date:
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