WF: NAW Intake FormNAW IntakeIntake Form for Neighbors at WorkWho referred you? How did you hear about our program or services?(Required)¿Quién lo referió? ¿Cómo se enteró de nuestros programas y servicios?NM – Neighbors at WorkNM – Housing Assistance ProjectNM – Parenting por Vida: CynthiaNM – Sueños Youth: Tania, Kendall or AlfonsoAccord HealthcareACYRArizona Collegiate High SchoolASDA – Arizona School of Dental AssistingCareer Success SchoolsCatholic CharitiesEmpower College PrepGateway Community CollegeGrad SolutionsHYC – Homeless Youth ConnectionNPHX Hope CenterOFY – Opportunity for YouthRio SaladoSociety SalonSouthwest Leadership AcademyYearUpYoungLivesOtherName of Person Who Referred YouNombre de la persona que te refirió:General InformationFirst Name(Required)Primer nombreLast Name(Required)ApellidoDate of Birth(Required)Fecha de Nacimiento Month Day YearGender(Required)SexoFemale / MujerMale / HombrePrefer not to say / Prefiero no indicarAgeNO – EmailCorreo ElectronicoEmailOnly enter your own email. If you do not have an email or use a parent’s email, leave blank. Phone Number(Required)Número de TelefonoOpt-In Consent(Required) By providing your phone number, you agree to receive text messages from Neighborhood Ministries, workforce development programs. Message & data rates may apply. Message frequency varies.View to Privacy Policy: https://nmphx.com/about/privacy-policy/Zipcode(Required)Codigo PostalPlease enter a number from 80000 to 90000.Language(Required)Idioma English Español English & Español OtherRace/Ethnicity(Required)Select ALL that apply. Hispanic/Latino American Indian/Alaska Native African American/Black Asian Native Hawaiian/Other Pacific Islander White Middle Eastern/North African Not SpecifiedNO! – Race/Ethnicity Hispanic/Latino American Indian/Alaska Native African American/Black Asian Native Hawaiian/Other Pacific Islander White More than one race/ethnicity OtherEmploymentEmpleoEmployment Status(Required)Estado de Empleo – empleo a tiempo parcial, tiempo completo o desempleado Part Time Full Time UnemployedCurrently EmployedActualmente empleado.What company do you work for?(Required)¿Para qué compania trabaja?What is your title?(Required)For example: Cashier, Stocker, Service Rep, etc. ¿Cuál es tu título? // Por ejemplo: Cajero, almacenista, representante de servicio, etc.When did you start at your job? Start date?(Required)¿Cuando comenzó en su trabajo? FechaMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is your hourly rate?(Required)¿Cuanto es su sueldo por hora?Are you looking to upgrade your employment by finding a new job?(Required)¿Está buscando mejorar su empleo encontrando un nuevo trabajo? Yes NoWhy are you looking for an employment upgrade?(Required)¿Por qué estás buscando una mejora de empleo? Salary or Financial Reasons // Salario o Razones Económicas Working Environment or Management // Ambiente de Trabajo o Administracion Career Development or Growth // Desarrollo o crecimiento profesional OtherNOT Currently EmployedNO actualmente empleadoWhat is the reason for not employed?(Required)¿Cuál es la razón de no estar empleado? Enrolled in Education // Matriculado en Educación Completed Seasonal or Temporary Employment // Empleo estacional o temporal completado Lost Job or Laid Off // Trabajo perdido o despedido Left Job or Quit // Dejó el trabajo o renunció Family Reason (Children, etc) // Motivo familiar (Hijos,etc) Disability or Injury // Discapacidad o lesión OtherHow long have you been unemployed?(Required)¿Cuánto tiempo llevas desempleado? Less than 3 months // Menos de 3 meses 3-6 months // 3-6 meses 6-12 months // 6-12 meses More than 12 months // Más de 12 mesesEducationEducaciónWhat is the Highest Grade you have completed?(Required)PreschoolKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12th1314In CollegeCollege GraduateMastersDoctorateWhat is the Highest Degree you have completed?(Required)No schooling completedUp to 8th gradeSome HS, no diplomaHS graduate, diploma or GEDEducation with workforce prepSome college, no degreeTrade/tech/voc trainingAssociate's degreeBachelor's degreeMaster’s degreeProfessional degreeDoctorate degreeEducation Status- Current(Required)Estado educativo – Actualmente Inscrito en la escuela / Fuera de la escuela (graduado o dejo de atender) Out of School In-SchoolType of School(Required)Tipo de escuelaTraditional School // Escuela TradicionalAlternative High School (ACYR, Hope College, etc.)Online High School (Grad Solutions, Career Online, etc.)Vocational or Technical Program // Programa Vocacional o Técnico2-Year College // Universidad de 2 años4-Year College or University // Universidad de 4 añosHow long have you been out of school?(Required)¿Cuánto tiempo has estado fuera de la escuela? Less than 3 months // Menos de 3 meses 3-6 months // 3-6 meses 6-12 months // 6-12 meses More than 12 months // Más de 12 mesesIf you dropped out, what was the reason for dropping out of high school?(Required)¿Cuál fue la razón por la que dejó de atender la escuela secundaria? Chronic Illness // Enfermedad crónica Chronic Absences // Ausencias Expelled / Long Term Suspension // Expulsado ó Suspensión Aged Out or Turned 21 years old // Cumplió 21 años Transferred to State Detention or Correctional Facility // Transferido a Detención Estatal o Centro Correccional Became Pregnant or Parent // Quedó embaraza o se covirtió en padre Had to Work // Tuvo que trabajar OtherIf you are not enrolled in post-secondary education (college, trade school, etc.), what is the reason?(Required)Si no está inscrito en educación postsecundaria (universidad, programa técnico, etc.), ¿cuál es el motivo? Work Full-Time // Trabajo de tiempo completo Don’t want to go further in education // No quiero continuar en la educación. Financial – Can’t afford further eduction // Financiero: no puede pagar más educación OtherPersonal & Household StatusAll answers and information are confidential. // Estado personal y del hogar. Todas las respuestas e información son confidenciales.Barriers – Select any that apply:Select if any of these barriers describe yourself currently or formerly. // Seleccione si alguna de las poblaciones se describe a sí mismo actualmente o anteriormente. Homeless or without Stable Housing // Sin Hogar o sin Vivienda Estable Pregnant or Parenting // Embarazada o Padre Foster Care // Acogimiento o Hogar Substituto Justice Involved // Involucrado en el Sistema de Justicia English Language Learner // Estudiante del Idioma Inglés Disabilities // DiscapacidadesPopulations – Select any that apply:Select if any of the populations that describe yourself currently or formerly. // Seleccione si alguna de las poblaciones se describe a sí mismo actualmente o anteriormente. Primary Caregiver or Financially Responsible for Dependents // Jefe de Familia Member of LGBTQ Community // Miembro de la comunidad LGBTQ Undocumented // Indocumentado DACA Recepient // Receptor de DACA Struggled with Substance Use // Luchó con el uso de sustancias Have Family Members have struggled with Substance Use // Tiene familia que ha luchado con el uso de sustancias Refugee or Asylum Seeker // Refugiado o Solicitante de Asilo Military or Veteran // Militar o Veterano None of the AboveHow many adults (18 or older) live in your household?(Required)Do NOT include yourself. // ¿Cuántos adultos (mayores de 18 años) viven en su hogar? – NO te incluyas a ti mismo. –How many youth (0-17) live in your household?(Required)Do NOT include yourself. // ¿Cuántos jóvenes (0-17) viven en su hogar? – NO te incluyas a ti mismo. –Total persons in HouseholdPublic Assistance – Does your household receive any of the following supportive assistance?(Required)¿Recibe su hogar alguna de las siguientes ayudas de apoyo? Food Stamps (SNAP) // Estampillas TANF SSI/SSDI AHCCCS WIC None of the Above // Ninguno de los AnterioresBasic Needs – Does your household have trouble meeting any basic needs?(Required)¿Su hogar tiene problemas para satisfacer alguna necesidad básica? Food or Nutrition // Alimentación o Nutrición Housing or Rent // Vivienda o Renta Utilities // Utilidades Transportation // Transporte Childcare // Cuidado de niños Work or Schools Supplies // Materiales para el trabajo o la escuela None of the Above // Ninguna de las anterioresBasic Needs & Public Assistance SummaryLast 5 Digits of SSN(Required)If you are unable to provide this number at this time, please enter: 00000 // Últimos 5 dígitos del SSN. Si no puede proveer este número en este momento, escribe: 00000By submitting this form, you acknowledge that participation in this program is completely voluntary. You are not required to enroll or participate in order to receive other federal, state, or city benefits. You also understand that enrollment in the program is contingent upon eligibility verification and is not guaranteed.
English