Westside Works Registration Form

Westside Works Registration Form

A Partnership Preparing Residents of Atlanta’s Westside for Employment Opportunities

Integrity w/o words CEFGA LEVY 1st step staffing - logo westside on the rise YMCA

Westside Works Registration Form

Email

First Name

Last Name

Client ID

Please enter the last 4 of your SS# and first and last initials. (example 1234FL-NO SPACES)

Date

Westside Works Programs

Please indicate which programs you are interested in? (hold control key for multiple programs)

Your Neighborhood

Gender

Race

Year of Birth

(yyyy) only

Birthdate

(mm/dd/yyyy) or use calendar

Address

City

State

Zip

Phone

(xxx-xxx-xxxx)

Preferred Phone

Profile Data

Profile Date

Today's Date

Are you a Veteran

Yes

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 Your Resume

Identification Section

Valid GA ID?

Yes

SS Card?

Yes

Birth Certificate?

Yes

GA Drivers License?

Yes

Drivers License Type

Education

Highest Education Level

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

Training you would you like to receive

Do not select more than 3 choices. (hold control key to select more than one choice)

Employment and Skills

Previous Positions Held

(hold control key to select more than one choice)

Position Seeking

(hold control key to select more than one choice)

Have You Been Laid Off From Work in the Last 12 Months?

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

Do you have a Criminal History Background?

Yes

Have you been convicted of a felony

Yes

If yes – when

enter the year for each offense (if several)

Do you need Legal Assistance

Yes

Referred By

Name or agency that referred you to this program?

Referral's Phone Number

(xxx-xxx-xxxx)

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?

Offense Type

(hold control key to select more than one offense type)

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

(weekly, bi-weekly, monthly,...ect...)

Probation’s/ Parole Officer Name

Profile Record Type

Westside Works Profile Records

itcdc

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New WW Web Form Submitted

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