Pinellas County Urban League - Client Profile Form

How may we help you?


NEXT STEPS: Affordable Care Navigator will be sent to your email
Thank you for completing Part 1. Please check your email for next steps for this application. A copy of this link will be sent to your email address.
NEXT STEPS: LIHWAP Application will be sent to your email 
Thank you for completing Part 1. Please check your email for next steps for this application. A copy of this link will be sent to your email address.

Client Profile Form













Healthcare Questionnaire


Demographics Information




























Household
List all of the genders and ages of dependent adults and children who live with you.


Urban Seniors Jobs Program Assessment

Enter your information




Serious Business Academy - Assessment Page 1

1. Enter details about your organization here

















Please list all owners and their percentages of ownership








Serious Business Academy - Assessment Page 2

9. Please rate your level competency in these areas









Serious Business Academy - Assessment Page 3


















Serious Business Academy - Assessment Page 4











Workforce Assessment Form



Current Employment
If you are currently employed, enter details of your employment here.








Previous Employment
If you had any previous employment, enter it here.

















Career Goals
What are your career goals? Us the space to explain what you would like to accomplish and how we can help you with the next year.



Weatherization Assistance Program - Quick Assessment








Fillable Form

STYLE Application

Please access and download the STYLES application at: HERE

Youth Empowerment Programs Assessment Page 1

Youth and Family Services is a robust all-inclusive set of programs and initiatives that assist youth and their families. The following serves as your general assessment for consideration into all such applicable programs and initiatives including STYLE and YEP. 






Contact Information





Education



Youth Empowerment Programs Assessment Page 2

Parent/Guardian Information







Emergency Contact



Youth Empowerment Programs Assessment Page 3

YEP 1



YEP 2




Youth Empowerment Programs Assessment Page 4

Medical Consent
CHECK THE OPTION THAT BEST MEETS THE MEDICAL RESPONSE FOR YOU AND/OR THE PARTICIPANT. INITIAL WHERE INSTRUCTED:

I UNDERSTAND AS THE PARENT/GUARDIAN OF THE PARTICIPANT, THAT I AM FULLY RESPONSIBLE FOR ENSURING THAT THE PARTICIPANT BRINGS SUFFICIENT AMOUNT OF ALL MEDICATIONS, PRESCRIPTIONS, SUPPLIES AND DEVICES REQUIRED FOR HIS/HER PROFESSIONALLY PRESCRIBED MEDICAL CARE, TO COVER THE FULL DURATION OF ALL ACTIVITIES.

I UNDERSTAND AS THE PARENT/GUARDIAN OF THE PARTICIPANT, THAT THE PARTICIPANT IS FULLY RESPONSIBLE FOR THE APPROPRIATE, TIMELY, CONSISTENT AND COMPLETE ADMINISTRATION OF ALL HIS/HER EXISTING, PROFESSIONALLY PRESCRIBED MEDICAL CARE, INCLUDING ROUTINE MEDICATIONS, ANTIBIOTICS, AND ORTHOTIC DEVICES AND WOUND CARE.





Affordable Care Act Navigator Program