Human Services Employment Ladder Program

Admissions Application

By completing and signing this document I do attest that all information provided in this admissions application is complete and accurate. I understand that should anything be knowingly omitted or falsified it is grounds for immediate program disqualification or termination.

I agree I disagree

Signature: ______

Administrative Use Only
Date Received:
TABE Test: Satisfactory Unsatisfactory
Ethical screening: Satisfactory Unsatisfactory
Help Essay: Yes No
Computer Skills: Satisfactory Unsatisfactory
Interview: Satisfactory Unsatisfactory
DTA:
MRC:
WIA/ITA Voucher:
Administrative Use Only
Excellent fit for the program (Accepted)
Needs improvement in some areas, but overall a good fit for the program (Accepted)
Not the right fit for the program, referred to anothertraining program (Denied)
Not the right fit at this time (Denied)
Not the right fit at all (Denied)

Attention:

Before completing this application please review the following program eligibility checklist, to be sure you meet all of the program qualifications.

Have a high school diploma or GED

Have a valid U.S. driver’s license

Willing to submit to a CORI check

Willing and able to work flexible schedules

2nd shift (3pm – 11pm)

3rd shift (11pm – 7am)

Holidays

Weekends

Overtime

Have a desire to help people

Can pass ethical, TABE, and computer screening

Do you have an updated resume?

Actively job searching or have a desire to be gainfully employed

Are you a member of the Boston Career Link?

How did you hear about this program? ______

______
______

General Information

Applicant Contact and Personal Information

Last name:First name:

Middle initial:

Home address: Apt #:

City: Zip code:

Home Phone #:

Cell Phone #:
Email address:

Date of Birth: Age:

Emergency Contact Information

Last name:First name:

Middle initial:

Home address: Apt #:

City: Zip code:

Home Phone #:

Cell Phone #:
Email address:

Do you have any dependents?

Yes

Are you a single parent?

Yes

Do you have a caseworker at any other agency?

Yes

If yes, check the appropriate agency and list the name of the worker(you may choose more than one response)

Department of Transitional Assistance (DTA)

Caseworker name: Phone #:

Massachusetts Rehabilitation Commission (MRC)

Caseworker name: Phone #:

Department of Mental Health (DMH)

Caseworker name: Phone #:

Department of Developmental Disabilities (DDS)

Caseworker name: Phone #:

Other:

Caseworker name: Phone #:

Are you currently receiving unemployment benefits?

Yes

Are you currently homeless?

Yes

If yes, are you in a shelter?

YesName of shelter:

If you are not homeless now, have you ever been homeless at any point in time?

Yes

Have you ever abused a substance?

Yes

If yes, what substance was it? (you may choose more than one response)

Alcohol

Drugs

Other

If other, identify here:

If yes, how long have you been in sobriety?

Less than 6 months

More than 6 months but less than 1 year

More than 1 year but less than 2 years

More than 2 years but less than 3

More than 3 years

Education

Please check all that apply to you

High school diploma

Some college courses but no degree

College degree

Associates

Bachelors

Masters

Doctoral

Certifications

Please check all that apply to you

Certified Nursing Assistant (CNA)

MAP Certified

Home Health Aide

First Aid/CPR

Other:

Program Specific Information

How did you hear about the HELP program? (you may choose more than one response)

Boston Career Link

Massachusetts Rehabilitation Commission (MRC)

Department of Transitional Assistance (DTA)

Goodwill employee:

Name:

Goodwill advertisement:

Location:

Friend/Family member:

Name:

Other:

Qualifications

Are you at least 21 years of age or older?

Yes

Do you have a valid U.S. Drivers license that has been in good standing for at least 1 full year?

Yes

I have a license, but I haven’t had it for 1 full year

I do not have a license and I do not want one

I do not have a license, but I am working on obtaining one

I do not have a license, but I am interested in obtaining one

Do you have a high school diploma or GED?

Yes

Name of high school or program: Year of graduation:

I am working on getting one

No, and I do not want one

Do you want to work with people?

Yes

Undecided

Are you willing to travel up to 10 miles outside of Boston/Salem for a position?

Yes

Do you have a reliable car?

Yes

Do you use public transportation?

Yes

When I have to

Are you willing and able to work weekends as needed?

Yes

Why:

Some weekends are ok

Are you willing and able to work 2nd shift (3pm – 11pm) as needed?

Yes

Why:

Some 2nd shifts are ok

Are you willing and able to work 3rd shift (11pm – 7am) as needed?

Yes

Why:

Some 3rd shifts are ok

Are you interested in working with individuals with Intellectual disabilities?