Skill Building Student Intake Form- English

Skill Building Student Intake Form- English

east somerville

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The Skill Building Program offers English Language classes to help support Somerville small business employees.

To qualify for the program, you must work for a small business in Somerville (fewer than 100 employees) and meet our income requirements.

For more information:

Please reach out to Jimmy Rao, jrao@masshiremetronorth.org

First Name

MI

Last Name

Preferred Name

Address Line (Include Unit/Apt # if applicable)

City

State

Postal Code

Do you have a Whatsapp number?

YesNo

What is your Whatsapp Number?

Do you have a Mobile Phone number?

YesNo

What is your Mobile Cell Number?

Do you have an email address?

YesNo

What is your email address?

What is your preferred method of contact?

WhatsAppPhoneEmailText

I Identify my race as: Check all that apply

American Indian/Alaskan Native AsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhite Prefer not to answerPrefer to self-describe

If you prefer to self-describe, please specify:

Are you Hispanic or Latino?

YesNoPrefer not to say

Which of the following best describes you?

FemaleMaleTransgenderNonbinary Prefer not to answer Prefer to self-describe

If you prefer to self-describe, please specify:

What is your hourly wage?

$15/hr-$18.99/hr$19/hr-$23.56/hr$24/hr-$36.06/hr$36.10/hr-$47.60/hr$48.08/hr-$71.63hr$72.12/hr-$96.15/hr$96.15/hr or more

How many hours do you work per week?

20 hours or less21-30 hours31-40 hours41-50 hours51-60 hoursMore than 60 hours

Does anyone else in your house work?

YesNo

If yes, what is their hourly wage?

$15/hr-$18.99/hr$19/hr-$23.56/hr$24/hr-$36.06/hr$36.10/hr-$47.60/hr$48.08/hr-$71.63hr$72.12/hr-$96.15/hr$96.15/hr or more

How many hours do they work per week?

20 hours or less21-30 hours31-40 hours41-50 hours51-60 hoursMore than 60 hours

Including yourself, how many people are in your household (e.g., family members and/or those supported by household income?

12345678>8

What is your age?

What language do you speak at home?

EnglishSpanishArabicChinese (Mandarin)Chinese (Cantonese)FrenchHaitian CreolePortugueseVietnameseOther

If you speak an other language, please specify:

Do you speak any other language(s) in addition to your first language?

YesNo

If yes, please select from the list below:

EnglishSpanishArabicChinese (Mandarin)Chinese (Cantonese)FrenchHaitian CreolePortugueseVietnameseOther

If other, please specify:

Do you identify as a person with a disability (with or without a diagnosis)?

YesNoPrefer not to answerPrefer to self-describe

If you prefer to self-describe, please specify:

Are you a veteran?

YesNo

What is your highest education level?

Less than HS Diploma/GEDHS Diploma/GEDAssociates/Some CollegeBachelor'sAdvanced Degree

What is the name of the business you work for?

What kind of business is it?

Retail- Store FrontRetail- OnlineFood/HospitalityFinancePlumbing/HVAC ElectricChildcareTechHealth CareArtsConstructionReal EstateOther

If other, please specify:

Please provide the details of your boss/manager below.

Name of your boss/manager:

Email address of your boss/manager:

Phone number of your boss/manager:

What is your role/job?

How long have you been working there?

What digital devices do you own? Check all that apply:

Mobile phoneLaptopTablet

Do you have reliable internet access?

YesNo

Please check the computer applications you are familiar with?

EmailInternet browsingVideo callingWord/Google DocsExcel/Google SheetsPowerPoint/Google SlidesOtherNone of the above

If other, please specify:

How did you hear about this program?

FlyerEmployerSocial MediaFriend/FamilyOther

If other, please specify:

Contact Information