ITCDC CARES

                                          

First Name

Last Name

Email

Which ITCDC Program are you Interested In?

Please select... Digital Literacy

Client ID

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

Lead Source

Please select... Web Form

New ITCDC Client From Web Form

Gender

Please select... Male Female

Race

Please select... Black - African American White Hispanic Latino Asian American Indian Other

Birthdate

Year of Birth

enter all 4 digits - 1964

Date 

Enter Today's Date

Record Type

ITCDC Record

Address

City

State

Zip

Phone

Preferred Email

Please select... Personal

Preferred Phone

Please select... Mobile

Select Your Neighborhood

Please select... Adair Park Ashview Heights Atlanta University Center Bankhead Capitol City Gateway Castleberry Hill English Avenue Grove Park Mechanicsville Other Peoples Town Pittsburg Vine City Washington Park Non-Atlanta Resident

How Did You Hear About US?

Please select... AARP Atlanta Public Schools CEFGA City of Refuge Facebook Faith Based/Church Organization Flier Instagram Integrity CDC Internet Probation/Parole Officer Quest Shelter/Transitional Housing Social Media Social Service/Government Agency TV/Radio Twitter Walk-In Word of Mouth YMCA Dept. of Community Supervision Community In Schools

Profile Data

Profile Date 

Enter Today's Date

Profile Record Type

ITCDC Profile Record

Are you a Veteran

Yes

ITCDC Program

Are you currently employed

Yes

First Name

Last Name

Re-Enter Client ID

How long have you been unemployed

Please select... 0-6 months 7-12 months 1-2 years 3-4 years 5 years or longer

Receiving any Assistance

Yesunemployment, Food Stamps, etc...

Type of assistance you are receiving

Please select... Food Stamps Disability SSI Unemployment Insurance Medicaid Medicare TANF WIC Child Care Housing Assistance Energy Assistance Mental Health Substance Abuse Services Aging Services Child Support Services Peachcare for Kids Other 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

Identification Section

Valid GA ID

Yes

Valid GA Driver's License

Yes

Drivers License Type

Please select... Regular (car) CDL (trucks) Other

Birth Certificate

Yes

SS Card

Yes

Education

Education Level (s)

Please select... High School Grad GED Technical College Community College College Degree Never Graduated Hold control key to select more than one answer

Degree Type

Please select... AS BS Technical MA PhD OtherHold control key to select more than one answer

Would you like to enter a GED program

Yes

Would you like to receive training

Yes

Training you would you like to receive

Please select... Accounting Administrative/Clerical Advertising/Marketing Airport Services Architecture Asbestos Abatement Attorneys Audio Visual Services Audio Visual Supplies Automotive Sales/Supplies/Services Background Investigation Banners/Tents Bridges/Tunnels Business Consultant Cable Services CADD Carpentry Catering CDL Class B Cement/Masonry Certified Forklift Operator Chemicals Handling/Supplies Child Care Development Child Development Associate City Planning/Urban Design Computer Services Computer Supplies Computers Concessions Concrete/Paving Construction Construction Management Construction Supplies Counseling Courier/Mailing Services Custodial/Janitorial Data Processing Debt Collection Demolition Development Driver Drywall Education Services Electrical Contracting Electrical Supplies Electricians Elevator Services Employment Services Engineering Environmental Consultant Equipment Supplies Erosion Control Excavation Facilities Management Fencing Film Production Financial Services Fire Protection Flooring Food Service Food Supplies Gas/Oil General Construction General Contracting General Labor Geotechnical Engineering Glass Services Glaziers/Glasswork Goods Supplies Grading Hauling Hazardous Material Management/Removal Hazardous Materials Handling Healthcare Services Heavy Construction Heavy Equipment Operation HVAC Hydraulics Information Technology/Computers Insulation Insurance/Bonding Interior Construction Interior Design Janitorial Services Janitorial Supplies Job Readiness Job Readiness/ Soft Skills Landscaping Maintenance Mapping Masonry Medical Medical Assistant Medical Billing and Coding Medical Supplies Moving/Storage Services Noise Abatement Office Furniture/Office Supplies Other Other Skills Painting/Wall Covering Parking Management Pest Control Phlebotomy Photography Pipe laying/Piping Plumbing Pressure Cleaning Printing/Graphics/Publishing Professional Training Promotions Property Management Public Relations Real Estate Recycling Renovations Retail Retail Food Retail Goods & services Roofing Security Services Signage Special Event Planning Steel Construction Stenography/Court Reporting Telecommunication Services Towing Services Traffic Control Transportation Services Trash Removal Uniforms Utilities Construction Visual Art/Sculpture Warehouse Warehouse/Logistics Welding Digital LiteracyDo not select more than 3 choices. (hold control key to select more than one choice)