Dad S Making a Difference

Participant Application

Please complete ALL sections of this application. Incomplete applications will not be considered.

GENERAL INFORMATION:Date of Application: ______

Name: Who referred you?

Social Security Number:______DOB: ______Age: ______

Address:______

StreetCity, StateZip

Resident of Wyoming since: ______U.S. Citizen: □ Yes □ No

Home Phone: ______Cell Phone: ______

Email Address: ______

What is your ethnicity?□ Hispanic or Latina□ White/Caucasian□ American Indian

□ Alaska Native□ Native Hawaiian□ Pacific Islander□ Asian

□ Prefer not to answer□ Black or African American

Marital Status:□ Married□ Divorced□ Single□ Separated□ Widowed

Marital status or cohabitation does not affect eligibility

Parenting Adult:□ Custodial □ Non-Custodial□ Related Guardian

(one or more bio children live with you)(no bio children live with you)(legal guardian, blood related)

Number of Children:

Are you:□ Employed Full Time (30+hours a week)□ Employed Part Time □ Unemployed

If yes, name and address of employer:

Current hourly wage: List income for last month:

List other wage earners in household:

FAMILYINFORMATION:

Current Dating/Married Relationship:

MISC INFORMATION

Court Ordered to PAYChild Support: □ Yes □ No If YES, Amount/month: ______

If YES, Case Worker Name:

If YES, Do you have back child support? Approximately how much?

Court Ordered to GET Child Support: □ Yes □ No If YES, Amount/month: ______

Are you currently receivingFood Stamps:□ Yes □ No If YES, Amount/month: ______

Do you currently receive child care assistance through the State of Wyoming? □ Yes □ No

Do you have health insurance? □ Yes □ No

Are you a veteran? □ Yes □ NoIf yes, do you have a DD214? □ Yes □ No

Are you currently in school? □ Yes □ No If YES, where?

Do you have: □ High School Diploma □ GED? If yes, graduation date:

If no, please indicate your plan to obtain your GED:

Do you have any special needs regarding education? □ Yes □ No

Do you have a: Valid Driver’s License □ Yes Dr. Lic. # ______□ No If NO, explain: ______

Personal Vehicle □ Yes □ No Reliable form of transportation □ Yes □ No

Type of CAREER desired through this program:______

WORK HISTORY:

Please provide information regarding previous jobs.Start with your current or last job. Include any military service assignments. Please attach a resume if you have one. FILL IN ALL INFO.

1. Employer Name: ______

Job Title: ______

Start Date: ______End Date: ______Hourly Wage: ______

Job Duties: ______

Reason for Leaving: ______

Contact Person: Phone:

2. Employer Name: ______

Job Title: ______

Start Date: ______End Date: ______Hourly Wage: ______

Job Duties: ______

Reason for Leaving: ______

Contact Person: Phone:

3. Employer Name: ______

Job Title: ______

Start Date: ______End Date: ______Hourly Wage: ______

Job Duties: ______

Reason for Leaving: ______

Contact Person: Phone:

EDUCATIONAL INFORMATION:

EMPLOYMENT OBSTACLES:

Any medical problems that may interfere with employment or training:______

Have you ever been convicted of a crime as an adult?□ Yes □ No

This does not affect eligibility in any way.Please include ALL convictions, even misdemeanors. These include but are not limited to: DUI, shoplifting, forgery, burglary, possession of a controlled substance, domestic violence, assault,, etc. Knowing this information simply helps us understand which supports you will need to get employed.

If yes, please explain: ______

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If on probation/parole, please list name and phone number of your probation/parole officer:

ESSAY QUESTION: Please explain what you hope to gain from participating in the Dads Making a Difference program – include how it might help your child(ren), you, your current relationship, your employment status, etc. Put a lot of thought into this response and include at least 75 words.

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ALTERNATE CONTACTS:

Please provide complete addresses and telephone numbers for THREE individuals who are NOT living in your home and who will know your whereabouts after completion of the program:

CERTIFICATION AND AUTHORIZATION

I AGREE to submit to monitored drug testing and/or breathalyzers throughout this program.

I CERTIFY, under penalty of law, that the above information is correct.

I UNDERSTAND that my statements may be verified.

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Applicant SignatureDate

DADS Application Rev. 06/2018