TRAC Associates King County Homeless Employment Enrollment Formpage 1 of 4

TRAC Associates – King County Homeless Employment Enrollment FormPage 1 of 4

SIG FRONT DOOR TO EMPLOYMENT
ENROLLMENT FORM

1. Social Security Number: ______/______/ ______
   
2. Intake Case Manager: ______Intake Date: ______
   
3. Last Name: ______First Name: ______MI ______
   
4. Birth Date: ____ /___ / ______Email ______Valid Driver’s License? Yes No

Reason if not valid ______

1. Address: ______
   City: ______State: ______Zip Code: ______
   
2. Phone (Area Code) Number: (______) ______- ______
   
3. In the past 12 months, what was your family income from all sources (in the USA), including:
   

INCOME SOURCE / AMOUNT (Total for past 12 months)
Wages/Salary / $______
Unemployment / $______
Welfare/TANF / $______
GAU / $______
Basic Food (Food Stamps) / $______
SSI / $______
SSDI / $______
Alimony / $______
Child Support / $______
Other (Specify) ______/ $______
TOTAL INCOME (All sources) / $______

1. How many people usually live in your household?
   1 (You) + _____ Other Family Members + _____ Other Non-Family Members =______TOTAL
   
2. Gender: Male Female Transgender-Male Transgender-Female
   
3. Ethnic Group (If you choose not to specify, please mark this box): N/A
   White Black, African-American, Other African American Indian or Alaskan Native
   Asian, Asian-American Native Hawaiian, Pacific Islander  Multiracial Unknown
   Other Race (specify): ______
   
4. Disability:
   Do you have a physical disability? Yes (specify):______No
   Do you have an emotional disability? Yes (specify): ______No

1. Veteran/Military Status (Please check only one):
   US Military (past or present)
   Spouses or partners of military person
   Military minor dependent
   No military service
   Unknown
   
2. Veteran Discharge Status
   Honorable
   General
   Medical
   Bad Conduct
   Dishonorable
   Not discharged – No active duty or still active
   Unknown
   
3. What is your current employment status? (Please check only one)
   Employed Full Time Employed Part TimeTemporary Worker
   Seasonal Worker Self-EmployedUnemployed
   
4. Are you currently participating in a program to help you get a job? Yes No
   II.) If “Yes,” through which agency?
   Workforce Development CouncilEmployment Security DepartmentApprenticeship Program DVR (Dept. of Vocational Rehab.) WorkFirst
   ADATSAOther (specify): ______
   
5. Do you have difficulty reading, writing, or speaking in English? Yes No
   
6. Which of the following classes have you ever attended? (Check all that apply)
   Adult Basic Education (ABE)English as a Second Language (ESL)None of theses
   Other (specify) ______
   
7. What is the highest grade of year of school you have completed OR the highest degree or certificate you have received? (Please check only one)
   

Below 8th Grade / 14th Year, but no Associate’s Degree
8th Grade / Associate’s Degree
9th Grade / 15th Year
10th Grade / 16th Year, but no Bachelor’s Degree
11th Grade / Bachelor’s Degree
12th Grade, but no HS Diploma or GED / 17th Year, but no Master’s degree
High School Diploma / Master’s Degree
GED Certificate / Beyond Master’s Degree
Technical/Vocational certificate or diploma
Specify: ______/ Other degrees or certificates
Specify: ______

1. Have you ever worked for pay? Yes  No
   
2. Have you ever worked full time (40 hours per week) for pay? Yes No
   
3. If unemployed, did you look for work in the last 4 weeks? Yes No
   
4. In the past 12 months, how many different employers have you worked for? ______
   
5. Are you seeking Full Time or Part Time work? Full Time Part Time Both
   
6. Current job (or last job if currently unemployed):
   a) Start Date (mm/dd/yyyy): _____/____/______End Date (mm/dd/yyyy): _____/____/______
   b) Still employed at this job: Yes No
   c) Employer Name: ______
   d) What is/was your job title in this position? ______
   e) How many hours per week do/did you usually work in this position? ______Hours per week
   f) Most recent hourly pay $______per hour. What was your starting wage? $______per hour.
   g) Why did you leave this job? (if applicable)
   Plant or division closed Quit Layoff
   Seasonal/temporary job ended Fired Other (specify):______
   
7. Next Previous Job (or 2nd Job if currently have more than 1 job):
   a) Start Date (mm/dd/yyyy): _____/____/______End Date (mm/dd/yyyy): _____/____/______
   b) Still employed at this job: Yes No
   c) Employer Name: ______
   d) What is/was your job title in this position? ______
   e) How many hours per week do/did you usually work in this position? ______Hours per week.
   f) Most recent hourly pay $______per hour. What was your starting wage? $______per hour.
   g) Why did you leave this job? (if applicable)
   Plant or division closed Quit Layoff
   Seasonal/temporary job ended Fired Other (specify):______
   
8. Do you have any children (including biological, adopted, and step children) who live with you?
   Yes No
   II.) If “Yes,” write in number of children in each age group:
   (_____)Under 4 yrs. old (_____)4-5 yrs. old (_____)6-12 yrs. old (_____)13-18 yrs. old (_____)19 or older
   
9. What is your marital status NOW?
   Married, living with spouse Married, not living with spouse Non-married partner
   Single/Never married Widowed, divorced, legally separated
   

1. Which one of the categories below best describes your current living situation? (Check one)

Rent a house or apartment / Transitional housing
I and/or a family member owns a house / Other living situation (specify): ______
Receive government assistance for housing / Live in Public Housing Community
Currently homeless / (If checked, which one?):______

1. Criminal History: Have you ever been convicted of a crime?

No / Yes (please describe): ______
______
Date ______Restrictions ______
______
Misdemeanor
Felony
Registered Sex Offender Restrictions ______
______

1. Are you currently on probation? Yes No
   If “Yes,” who is your probation officer? ______
   
2. What is your current citizenship status? US Citizen Refugee Resident Immigrant
   
3. Emergency Contact
   Last Name: ______First Name: ______
   Relationship: Spouse/domestic partner Father Mother Brother Sister Friend
   Other relative Other: ______
   Address: ______
   City:______State: ______ZIP:______Phone: (_____)_____-______
   

33. SIGNATURE:______/ Date: _____/_____/_____

CASE MANAGER CERTIFICATION
Notes:______
Case Manager: ______Signature: ______Date: ______