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ABOUT
PROGRAMS
DONATE
BUILDING HISTORY
Client
First Name
Last Name
Mobile Phone
Personal Email
Mailing Zip/Postal Code
Birthdate
How can JVS help you?
Help to go to school (example: earn a high school diploma, college preparation, or English classes)
Job training programs (example: bank career, nursing assistant, food service, hospitality, pharmacy technician, or animal care technician)
Help to get a job (example: career coaching, vocational English classes, financial coaching, resume help, or job fairs)
Do you currently have a job?
Yes
No
Have you ever had a job before?
Yes
No
Have you ever worked at any job for more than 3 months?
Yes
No
Do you want a full-time job now or
after
completing the job training
?
Yes
No
Are you authorized to work in the United States?
Yes
Prefer not to answer.
Do you currently receive any of the following benefits or resources?
SNAP (Food Stamps)
TAFDC (Cash Assistance)
Housing – Shelter
Housing – Subsidized (Section 8)
Childcare
None of the above
Do you want to receive
any of the these benefits or resources in the future?
SNAP (Food Stamps)
TAFDC (Cash Assistance)
Housing – Shelter
Housing – Subsidized (Section 8)
Childcare
None of the above
Do you have a High School Diploma or GED/HiSet (from U.S. or other country)?
Yes
No
Do you have a computer or device?
I have my own computer or device
I share a computer or device
No, I do not have a computer or device
Do you have internet access?
Yes
No
What is your level of experience with a computer?
Beginner
Intermediate
Expert
What country were you born in?
Please select…
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Brazil
Bulgaria
Burkina Faso
Burma (Myanmar)
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Congo
Costa Rica
Croatia
Cuba
Czechia
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Eritrea
Ethiopia
Ethopia
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong (China, SAR)
Hungary
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Korea
Kosovo
Kyrgyzstan
Laos
Latvia
Lebanon
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mexico
Moldova
Monaco
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nepal
Netherlands
New Zealand
Nicaragua
Nigeria
Norway
Other
Other – please add comments
Pakistan
Panama
Paraguay
Peru
Philippines
Phillipines
Poland
Portugal
Puerto Rico (USA)
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
Saudi Arabia
Senegal
Serbia
Sierra Leone
Singapore
Slovakia
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Tibet
Togo
Trinidad and Tobago
Tunisia
Turkey
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uzbekistan
Venezuela
Vietnam
Yemen
Zambia
Primary Language
Please select…
Afaan Oromo
Albanian
Amharic
Ao
Arabic
Armenian
ASL (American Sign Language)
Azeri
Bengali
Bini
Bosnian
Bulgarian
Burmese
Cantonese
Cape Verdean Creole
Cebuano
Chibemba
Chinese
Croatian
Dari
Dinka
English
Farsi
French
Fulani
German
Greek
Gujarati
Haitian Kreyol
Hebrew
Hindi
Hungarian
Igbo
Italian
Japanese
Karen
Khmer (Cambodian)
Kibembe
Kinyarwanda
Kirundi
Korean
Krahn
Krio
Kunama
Kurdish
Kyrgyz
Laotian
Lingala
Lithuanian
Luganda
Malay
Mandarin
Mandingo
Mende
Mongolian
Nepali
None
Not Disclosed
Nuer
Other
Parsi
Pashtu
Patois
Persian
Polish
Portuguese
Pular
Punjabi
Romanian
Russian
Shona
Slovak
Somali
Spanish
Swahili
Swedish
Tagalog
Tamil
Thai
Tibetan
Tigrinya
Turkish
Twi
Ukrainian
Urdu
Vietnamese
Wolof
Yoruba
What is your English language level?
Beginner
Intermediate
High or Fluent
Have you ever been a JVS client before?
Yes
No
We have specialized supports for individuals with a documented disability. Do you have a disability that you wish to disclose?
Yes
No
Are you over 17 and under 35?
Yes
No
Are You over 18 and under 24?
Yes
No
Amplify
yes
no
ArLab
yes
no
Submission URL
Contact Information
