WorkTexas Intake Application

Welcome!

Please select a language other than English.

Please select the location where you would like to attend the information session.

You will receive more information about the required information session once you submit the application.

Instructions

We're excited that you've decided to apply for admission to WorkTexas!

The online application for admission is broken down into several small pages. Please complete the information on each page, review your information at the end, then submit your application.

Keep in mind that:

All fields marked with an asterisk (*) on the application are required.
You must have scripting enabled on your browser in order for the application to function properly.
You must click the 'Submit' button at the end to send your application to our Enrollment Team.
Review your application at the end before you submit it.

At this time, you have to finish the application in one sitting. If you leave the form idle for more than 20 minutes, your session will expire, and you will have to start over!

PERSONAL INFORMATION

First Name

Middle Name

Last Name

Last Name Suffix

Note: The answers to these questions DO NOT affect your ability to participate in our training programs. These answers will help the WorkTexas team determine if you are eligible for additional support such as: paid internships (Work Based Learning), additional training, transportation support (bus passes/gas cards), and more-- all services provided by our partner, Workforce Solutions.

Date of Birth

Ethnicity/Nationality

Gender

Hispanic Origin

Income

Are you disabled?

Have you been unemployed for the last 26 weeks?

Are you currently receiving unemployment Insurance Benefits?

Have you received or exhausted Unemployment Insurance benefits within the last 6 months?

Are you a recent immigrant?

Are you a refugee or internally displaced?

Are you part of the LGBT+ community?

Do you have limited English Proficiency?

Are you a veteran?

Are you a spouse of a military veteran?

Have you ever been a foster care child?

Cell Phone Number

Alternate Phone Number

WorkTexas uses text messaging to keep you informed. Check to opt in.

Yes. Send me text notifications.

Email

name@domain.com

T-Shirt Size

What is the primary reason you are interested in enrolling in training at WorkTexas?

Referral Source - How did you hear about WorkTexas?

Other - Please Type your Referral Source Here

Address

What part of town do you live in?

Address Line 1

Address Line 2

City

State

Zip Code

County

Are you Authorized to Work in the US?

Note: If no, you are still eligible to attend our training.

Do you Have a Social Security Card?

Note: If yes, please bring it with you to Onboarding Day. If no, you are still eligible to attend our training.

Do you Have State ID?

Note: If yes, please bring it with you to Onboarding Day. If no, you are still eligible to attend our training.

Do you Have a Driver License?

Note: If yes, please bring it with you to Onboarding Day. If no, you are still eligible to attend our training.

Do you Have a Copy of Your Birth Certificate?

Note: This is only needed if you do not have an ID and interested in receiving additional support from Workforce Solutions.

Primary Language Spoken

Are you bilingual?

YesNo

Which languages do you speak?

EDUCATION

Are you currently attending school?

If No, what is the highest level of education completed?

Are you a High School Graduate?

YesNo

Which High School did you graduate from?

When did you graduate High School? (Date: mm/dd/yyyy)

If Yes, what are you currently enrolled in?

Which high school are you currently attending?

Are you in a dual credit course at HCC?

YesNo

If you are a male over the age of 18, have you registered for selective service?

Note: If no, please click on this link www.sss.gov, review and register. Not registering limits your ability to obtain federal financial aid to include Workforce Solutions funding.

WORK EXPERIENCE

Are you currently Employed?

If you are currently Unemployed, are you looking for work?

What type of work are you looking for?

Private	Medicaid
Medicare	CHIP
CHIP Perinatal	None
Other Insurance Type

Free or Reduced Price Lunch	Other State/Local Public Assistance
Refugee Assistance	SNAP
Social Security Disability Insurance	Social Security Income
TANF	Ticket To Work Program Holder
Trade Act Insurance	Unemployment Insurance
No. I have not received government assistance within the last 6 months

Childcare	Clothing
Financial	Food
Health Needs	High School Diploma (Up to Age 26)
Homeless	Job Training/Employment
Medication Needs	Mental Health Needs
Pregnancy	Transportation
None