WorkTexas Intake Application

Welcome to the WorkTexas Intake Application!

Next Gen

Yes

To sign up for WorkTexas training, you will need to complete the following steps:

Complete the Intake Application
Attend an Information Session
Get Screened for Eligibility
Attend Ganas Boot Camp

Review your application before you submit it. If you leave the form idle for more than 20 minutes, your session will expire and you will have to start over!

Acknowledgement

WorkTexas offers training programs designed to prepare participants for employment. These programs involve focused learning followed by active job search efforts. By clicking yes below you acknowledge that you are interested in pursuing training for employment or career advancement purposes. By clicking no, you understand that WorkTexas is not the most suitable training environment. Please feel free to reapply when you are seeking training for employment or career advancement purposes.

YesNo

Reason for Applying

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

To gain skills that can help me get a job.To gain new skills that I can utilize at my current job.To gain skills that will help me get a better job or advance in my career.

Personal Information

First Name

Middle Name

Last Name

Last Name Suffix

Date of Birth

Contact Information

Cell Phone Number

Alternate Phone Number

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

Yes, sign me up for text messages.

Email

name@domain.com

Please confirm your email

name@domain.com

Email Message

Address Line 1

Address Line 2

City

State

Zip Code

County

Page 2

Demographic Information

Gender

MaleFemaleOther

Income

What is your household size (including you)?

	Yes	No
Are you a recent immigrant?
Are you a refugee or internally displaced?

Page 5

Screening Questionnaire

The answers to the next set of questions are used to predetermine any potential scholarships and funding opportunities for you. The answers DO NOT affect your ability to move forward with the enrollment process for our trainings.

	Yes	No
Are you authorized to work in the United States?
Do you speak, read, write and understand the English language?
Are you currently enrolled in High School?
Are you or have you ever been in the foster system?
Are you pregnant or expecting a child?
Are you a parenting youth (between the ages of 16 - 24)?
Are you homeless, "couch surfing", or a runaway?
Have you been involved in the justice system?
Do you have or have had an incarcerated parent?
Are you or have you been a victim of human trafficking?
Do you have a disability?
Are you or anyone in your household currently receiving or (within the last 6 months) received SNAP or TANF benefits?
Is anyone in your household eligible to receive free or reduced lunch?
If not working, were you terminated or laid off AND eligible for OR exhausted Unemployment Insurance benefits?
Are you currently receiving unemployment insurance benefits?
Have you been unemployed for the last 26 weeks (6 months)?
Are you a veteran of the United States?
Is your spouse a veteran of the United States?

English	Spanish
Arabic	Hindi
Vietnamese	Portuguese
Yoruba	Ibo/Igbo
Swahili	French
Other

Childcare	Clothing
Financial Coaching	Food
Health Needs	Education (High School Diploma or GED)
Housing (Homeless)	Job Training/Employment
Medication Needs	Mental Health Needs
Prenatal Care	Transportation
None

Private	Medicaid
Medicare	CHIP
CHIP Perinatal	None
Other Insurance Type