Reentry Registration 2019

You mush have an email address. Contact Staff if you don't have an email address!

First Name

Last Name

Date

Enter Today's Date

Record Type

ITCDC Record

ITCDC Program

Client ID

Please enter the last 4 of your SS# and first and last initials. (example 1234FL)

Lead Source

New ITCDC Client From Web Form

Gender

Race

Birthdate

Year of Birth

Phone

Do you live in the English Ave/Vine City Area

Yes

Preferred Email

Preferred Phone

Profile Date

Enter Today's Date

Profile Record Type

ITCDC Profile Record

Are you a Veteran

Yes

ITCDC Program

Client ID (again)

Please enter the last 4 of your SS# and first and last initials. (example 1234FL)

Are you currently employed

Yes

Please Type Your Full Name (again)

First Name and Last Name

How long have you been unemployed

Receiving any Assistance

Yesunemployment, Food Stamps, etc...

Type of assistance you are receiving

Hold control key to select more than one answer

Do you have any Mental or Physical Disabilities

Yes

Please Explain Disability

Is transportation an issue or problem

Yes

Explain transportation problems

Do you have a Resume

Yes

Upload You Resume

Do you have a valid Drivers License

Yes

Drivers License Type

Education Level (s)

Hold control key to select more than one answer

Degree Type

Hold control key to select more than one answer

Would you like to enter a GED program

Yes

Would you like to receive training

Yes

Previous Positions Held

(hold control key to select more than one choice)

Position Seeking

(hold control key to select more than one choice)

Barriers finding employment

Yes

What are your barriers finding employment

Have you used drugs in the last 30 days

Yes

Are drugs an issue with you

Yes

Would you like drug treatment info

Yes

Will drugs hinder you from employment

Yes

Have you been convicted of a felony

Yes

If yes – when

Do you need Legal Assistance

Yes

Referred By

Name or agency that referred you to this program?

Referral's Phone Number

Your SSN must be in 999-99-9999 format.

Valid SS Card

YesDo you have a valid SS card?

Your SS #

Format (123-45-6789)

Valid Birth Certificate

YesDo you have a valid Birth Certificate?

Number of Misdemeanor Convictions

Date of most recent Misdemeanor

Please explain Misdemeanor Convictions

Number of Felony Convictions

Date of most recent Felony

Please explain Felony Convictions

Are you currently on probation?

Yes

Are you bonded?

Yes

Please explain your probation

Probation’s/ Parole Officer Name