Welcome to Mi Casa Resource Center!

We would like to ask some questions about you and your household. The information you provide will be kept confidential and used by Mi Casa to serve you better. Providing us this information allows us to continue to offer free and low-cost services to you and the rest of the community. Please answer all questions to the best of your knowledge. 
Nos gustaría hacer algunas preguntas sobre usted. La información que usted proporcione será guardada en estricta confidencialidad y utilizada solamente por Mi Casa y nuestros socios del programa para servirle más eficazmente. Por favor, responda todas las preguntas a su mejor entender.

Personal Information / Información Personal























Demographic Information / Información Demográfica



Educational and Professional Experience / Experiencia Profesional y Educativa




Please enter your personal annual income for each category. If a category does not apply to you, enter $0.
Ingrese sus ingresos anuales personales para todas las categorías. Ingrese 0 si la categoría no se aplica a usted.

If you do not know your annual income for a category, please enter the amount you make/receive on a weekly, bi-weekly, or monthly basis in the category box and select that frequency.
Si no sabes su ingreso anual para una categoría, ingrese la cantidad de ingresos semanal, quincenal o mensual y elige esa frecuencia para la categoría.














TANF, SNAP, SSI/SSDI, etc



Social security, investment accounts, etc



If this number is not correct, please adjust the income categories above / Ajuste las categorías anteriores si este número es incorrecto
Hidden


Referral Information



Affidavit of Immigration Status / Declaración Jurada de Estatus Migratorio

Colorado Department of Labor & Employment Workforce Development Programs / Programas de desarrollo de la fuerza laboral del Departamento de Trabajo y Empleo de Colorado
In accordance with the Colorado Revised Statutes 24-76.5, you must possess one of the following forms of identification (ID). Check the appropriate box and provide the ID number and the expiration date, if any. If you do not possess one of the forms of ID listed and do not provide the requested information, your benefits may be denied. / De acuerdo con los Estatutos revisados ​​de Colorado 24-76.5, debe poseer una de las siguientes formas de identificación (ID). Marque la casilla correspondiente y proporcione el número de identificación y la fecha de vencimiento, si corresponde. Si no posee una de las formas de identificación enumeradas y no proporciona la información solicitada, es posible que se le nieguen los beneficios.



I was born or naturalized in the United States and subject to the jurisdiction thereof.

Upload a (PDF, PNG, JPEG, JPG) front and back of your ID File. Birth Certificate, U.S. Passport, Certificate of Citizenship, Naturalization Certificat


Upload a (PDF, PNG, JPEG, JPG) front and back of your ID File

I have been given the privilege, according to U.S. immigration laws, of residing permanently in the United States as an immigrant, and that this status has not been revoked, and has not been administratively or judicially determined to have been abandoned.

Upload a (PDF, PNG, JPEG, JPG) front and back of your ID File

You need to provide one form of identification. If you don't have an identification listed below, select "Not applicable / Ninguna de las anteriores" and provide other type of identification. / Necesitas proveer una forma de identificación. Si no cuentas con una de la lista, selecciona "Not applicable / Ninguna de las anteriores" y provee otro tipo de identificación.





Upload an image (PDF, PNG, JPEG, JPG) of your ID File


Upload an image (PDF, PNG, JPEG, JPG) of your ID File



Upload an image (PDF, PNG, JPEG, JPG) of your ID File



Upload a (PDF, PNG, JPEG, JPG) of your ID File



Upload a (PDF, PNG, JPEG, JPG) of your ID File



Upload a (PDF, PNG, JPEG, JPG) of your ID File



Upload a (PDF, PNG, JPEG, JPG) of your ID File



Upload a (PDF, PNG, JPEG, JPG) of your ID File



Upload a (PDF, PNG, JPEG, JPG) of your ID File



Upload an image of your ID File


Affirmation

Electronic Signature / Firma Electrónica

I affirm under penalty of perjury that the above information is true to the best of my knowledge. I understand that my lawful presence in the U.S. will be verified before workforce program services can be provided. I affirm that I am a U.S. citizen, legal permanent resident, or am otherwise lawfully present in the U.S. I understand that there are severe penalties for providing false statements and willfully misrepresenting information in order to obtain or increase workforce program services. I authorize the release of all information to determine my eligibility for workforce program services. I understand this may include release of information from former employers, verification with the U.S. Bureau of Citizenship and Immigration Services, and sharing of information with other public agencies in the performance of their public duties in accordance with the Colorado Employment Security Act 8-72-107.

Afirmo bajo pena de perjurio que la información anterior es verdadera a mi leal saber y entender. Entiendo que mi presencia legal en los EE. UU. se verificará antes de que se puedan proporcionar los servicios del programa de fuerza laboral. Afirmo que soy ciudadano de los EE. UU., residente permanente legal o que estoy presente legalmente en los EE. UU. Entiendo que existen sanciones severas por proporcionar declaraciones falsas y tergiversar información intencionalmente para obtener o aumentar los servicios del programa de fuerza laboral. Autorizo ​​la divulgación de toda la información para determinar mi elegibilidad para los servicios del programa de fuerza laboral. Entiendo que esto puede incluir la divulgación de información de antiguos empleadores, la verificación con la Oficina de Servicios de Ciudadanía e Inmigración de EE. UU. y el intercambio de información con otras agencias públicas en el desempeño de sus funciones públicas de acuerdo con la Ley de Seguridad Laboral de Colorado 8-72- 107.



CONSENT TO RELEASE AND EXCHANGE INFORMATION

Individual/Participant whose information is to be disclosed:

I authorize Denver Workforce Services and its contracted service providers (including, but not limited to: Ability Connection Colorado, Center for Employment Opportunities, Denver Public Schools, Urban Peak, and Eckerd Connects (collectively, the “Service Providers”)) to release/exchange any information that I have shared with Denver Workforce Services and/or the Service Providers with any educational, training, counseling, worksite, employer, social services, or criminal justice agency (collectively, the “Agency” or “Agencies”) for the purpose of assessment and enrollment into Denver workforce programs and/or ongoing support to reach my career, training, and/or educational goals. I also acknowledge that the identity of the Service Providers may change at the discretion of the City.

I authorize Denver Workforce Services and the Service Providers to release/exchange any information that I have shared with Denver Workforce Services and/or the Service Providers with other Agencies regarding any of the following: employment, unemployment, wage information, education and training, foster care, residence, health/mental health, family income, offender status and law enforcement/court records, extra-curricular activities, career plans and activities, and other government assistance. I understand that access to certain Denver workforce programs and services may be limited or denied without my consent to exchange information with other Agencies.

I have the right to inspect and copy the information released/exchanged from Denver Workforce Services and/or its Service Providers. I also understand that any information released/exchanged will be kept confidential in conformance with applicable law and will be used only to determine eligibility and appropriateness for Denver workforce programs and provide ongoing support to reach my stated goals.

This release will remain valid for one (1) year after the earlier of: 1) completion of services; or 2) the termination of my involvement with Denver Workforce Services. This authorization may be discontinued, by me, at any time with a written request submitted to Denver Workforce Services. I understand that any such revocation shall not affect disclosures previously made by Denver Workforce Services or the Service Providers.
Electronic Signature / Firma Electrónica

I have read the above statements and understand all of its provisions. I hereby willingly agree to release/exchange my information as described above:



Household Information / Información sobre su hogar







Including yourself, how many of the people in your household are...
Cuántos miembros de la familia u otros miembros de su hogar, incluyendose a usted mismo, tienen edad... 


If this number is not correct, please adjust the age ranges above / Ajuste las categorías anteriores si este número es incorrecto


Please enter your household members' combined annual income for each category. Do not include your own personal income.
If your household members have no income in a category, enter $0.

If you do not know the annual income for a category, please enter the amount they make/receive on a weekly, bi-weekly, or monthly basis in the category box and select that frequency.

Ingrese el ingreso anual combinado para los miembros de su hogar en cada categoría. No incluya su ingreso personal.
Si los miembros de su hogar si no tienen ingresos en una categoría, ingrese 0 por la categoría.

Si no sabes sus ingresos anual para una categoría, ingrese la cantidad de ingresos semanal, quincenal o mensual y elijas esa frecuencia para la categoría.














TANF, SNAP, SSI/SSDI, etc



Social security, investment accounts, etc



If this number is not correct, please adjust the income categories above / Ajuste las categorías anteriores si este número es incorrecto







Your most recent employer









Your employer before that












5a. Please list conviction date, sentence, and state




Releases / Descargo de responsabilidad

Photo, Video, and Audio Release / Autorización para medios de comunicación 

Mi Casa likes to share stories of our participants to foster hope and inspiration in the community, as well as giving insight into the work we do. Will you give your consent to Mi Casa and its partners to use photographs, video footage, audio recordings, and written testimonials for the purpose of advertising, marketing, or discussing the organization's work?
En Mi Casa, nos gusta compartir historias de nuestros participantes para fomentar la esperanza y la inspiración en la comunidad, a la vez que informamos acerca del trabajo que hacemos. ¿Autoriza a Mi Casa y sus socios usen fotografías, filmaciones, grabaciones de audio y testimonios escritos con el fin de publicitar, comercializar o analizar el trabajo de la organización?


Release of Liability / Exoneración de Responsabilidad

I understand the activities may have an element of hazard and inherent danger, and I take full responsibility for the actions and physical condition of myself. I hereby release and forever discharge Mi Casa and Mi Casa's officers, directors, and employees of any liability, claim, or damage for any injury or loss I may incur by my participation. In the event of an emergency, I give permission to transport myself to a hospital and to secure medical care. 
Entiendo que es posible que las actividades tengan un componente de riesgo y un peligro inherente. Asumo total responsabilidad por mis acciones y estado físico. Por el presente, exonero permanentemente a Mi Casa y a sus ejecutivos, directores y empleados de toda responsabilidad, reclamo o daños y perjuicios por cualquier lesión o pérdida que sufra como resultado de mi participación. En caso de emergencia, doy mi consentimiento para que me trasladen a un hospital y se obtenga atención médical. 


Information Sharing / Divulgación de información

Information collected from registration forms, questionnaires, and meetings with staff and partners may be used confidentially to help Mi Casa and its partners to evaluate and coordinate services. I grant permission to Mi Casa and its partners to share data confidentially among each other and with outside evaluators for the purpose of evaluating and coordinating services.
La información recabada a partir de los formularios de inscripción, los cuestionarios y las reuniones con el personal y colaboradores se podrá utilizar confidencialmente a fin de que Mi Casa y sus colaboradores puedan evaluar y coordinar los servicios que ofrecen. Otorgo permiso a Mi Casa y a sus colaboradores a divulgar datos de forma confidencial entre sí y con evaluadores externos a efectos de evaluar y coordinar servicios.


By electronically signing and entering today's date below I am certifying that I am the person who has completed the information on this form, that to the best of my knowledge, the information on this registration form is true, and I am aware of the release of liability, information sharing, and photo, video, and audio release statements above. Should you have a problem or complain regarding Mi Casa's programming or staff, please contact Mi Casa's Senior Director, Pathways at (303) 539-5606. 
Al firmar electrónicamente y escribir la fecha de hoy abajo, certifico que soy la persona que completó la información en este formulario y que, a mi leal saber y entender, dicha información es auténtica, y entiendo a lo que se refiere el párrafo que antecede en lo que respecta a la exoneración de responsabilidad legal, la autorización para medios de comunicación, y la divulgación de información. En caso de tener algún problema o queja con respecto a los programas o el personal de Mi Casa, comuníquese con Directora sénior, programas al (303) 539-5606.
Electronic Signature / Firma Electrónica

I agree that by typing my full name in the box below and entering today's date, I am electronically signing this form.
Estoy de acuerdo en que al escribir mi nombre completo y la fecha de hoy en los cuadros de abajo, estoy firmando electrónicamente este formulario.


Mi Casa Resource Center
345 S Grove St, Denver, CO 80219
Main Line: (303) 573-1302
Business Hours: Mon-Thurs 8 a.m. - 6 p.m. | Fridays 8 a.m. - 4:30 p.m.
http://www.micasaresourcecenter.org/ | info@MiCasaResourceCenter.org