Family Self-Sufficiency Program – Pre-Enrollment Form

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Family Self-Sufficiency Program Pre-Enrollment Form
Address
Address
City
State/Province
Zip/Postal
Country

Please list all family members who live in your housing unit, including the head of the household. Give the relationship of each family member to the head of household.
Sex*
Ethnicity*
Are you (head of household) employed?*
Per
Are any other family members employed?*
Please check any item below that you consider a current need
Please check the different agencies you have visited or received services from in the last six months.
Do you speak English?
Do other family members speak English?
Do you have a high school diploma or GED?
If you were to get a job or change your job, would you need help finding someone to watch your children (child-care)?
Do you now work with one person or a case manager who helps you and your family find the services you need?
Ar you curently receiving Case Management Services from another agency?