Creating Futures Program (WIOA) Serving Benton, Cedar, Iowa, Johnson, Jones, Linn, and Washington counties Social Security # Referred by: Name First Middle Last, Jr., Etc. Other Name(s) Residence address City State Zip Mailing address (if different from residence) County of Home Cell Residence Phone Phone Are you E-­‐Mail Homeless? Yes No Address Date of Birth Age Sex: Male Female Are you a citizen or National of the United States? Yes No If no, are you authorized for employment? Yes No If yes, what is your INS Alien Number: # If no, please explain: Are you registered with selective service? (Male 18 years of age or older) Yes No Are you a veteran? Yes No If Yes, years of service: to Ethnic Group White Hispanic/Latino Asian/Pacific Islander Please circle one. Black American Indian/Alaskan Native Unknown Marital Status: Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed ( ) Demographics Yes No Yes No Are you currently enrolled in school? Are you a runaway? Are you a high school drop out? Are you currently in foster care or an out-­‐of – home placement? Are you or were you in special education or classes for learning disabilities? Did you age out of foster care? Do you have a disabil+++++++++ity? Is English your first language? Have you ever been charged or convicted of a Do you need additional assistance to misdemeanor or felony? complete an educational program? Are you a parent? Do you need additional assistance to secure If yes, how many children? ___________ or maintain employment? Are you the mother or father of an unborn child? If yes, expected due date __________ Education What is the highest grade you’ve completed in school? ____________ What is the date you last attended school? _____________ Name of school: __________________________________________ Are you in danger of dropping out of school? Yes No Are you interested in additional education/training? Yes No When? Where? . Program: Are you receiving a PELL grant? Yes No Employment Information Are you employed? Are you laid off? Are you receiving Unemployment Compensation? Are you a child of a parent who is laid off? Have you been looking for work? Work History Please start with the last job you had or the job you have now. Yes No Employer: Address City State Zip Job Title Hourly Wage $ Hours per Week Date Started / / Date Left / / Reason for Leaving City State Zip Job Title Hourly Wage $ Hours per Week Date Started / / Date Left / / Reason for Leaving City Zip Job Title Hourly Wage $ Hours per Week Employer: Address Employer: Address Date Started / / Date Left / / Reason for Leaving Family Size/Income Write your name and the names of all persons who live at your address (including children) and other family members temporarily living elsewhere. Then list any income they have received in the last six months. Income Received Last 6 Relationship to Months Before Taxes Name Birth Date Applicant From Where? $ $ $ $ $ $ If you are a full time student and 23 years of age or younger, who claimed you last year on their income taxes? Parent/Guardian ( ) Self ( ) Check if you or anyone in your family listed above gets one or more of the following: Monthly Monthly Amount Amount Family Investment Program $ Food Stamps (Anytime in the last 6 months) $ Free or Reduced Lunch WIC SSI (Supplemental Security Income) Aid to Refugees $ $ $ $ I certify the information I have provided on this application is true to the best of my knowledge. I am also aware that the information I have provided may be reviewed and verified, and that I may have to provide documents to support this information. I allow release of this information for documentation purposes. I authorize the release of information (including Iowa Workforce Development for Job Insurance Information) for purpose of verification of program eligibility and determing need. Further, I understand that this information will be used to determine my eligibility for programs under the Workforce Innovation and Opportunity Act (WIOA). I am aware that I am subject to immediate termination and that I may be prosecuted for fraud if I am found ineligible after enrollment. Also, I authorize the use of my Social Security Number as an identifier for WIOA program administration purposes. I have been provided a copy of the WIA Equal Opportunity Policy. PLEASE SIGN IN CURSIVE AND IN INK. Applicant Signature: Date: _____________________ FOR APPLICANTS UNDER THE AGE OF EIGHTEEN (18): As the Parent/Legal Guardian of the above applicant, I certify by my signature below that the information provided is correct to the best of my knowledge and that, if accepted; my dependent may participate in the Creating Futures Program. Parent/Guardian Signature: Date: _____________________ Creating Futures Consultant Signature: Date: _____________________ EQUAL OPPORTUNITY NOTICE The Creating Futures Program (Kirkwood Community College, Administrative Entity) endorses the principal of equal educational and training opportunities for all people, regardless of race, color, creed, sex, marital status, religion, ancestry, national origin, sexual orientation, age, handicap or disability, in the programs/activities it operates. Visit our website at www.kirkwood.edu/creatingfutures Completed applications may be returned to: IowaWORKS/Skills to Employment IowaWORKS/Skills to Employment Kirkwood Community College Kirkwood Community College st
4444 1 Ave NE Suite 436 1700 South First Avenue – Suite 11B Cedar Rapids, IA 52402 Iowa City, IA 52240 319-­‐365-­‐9474 319-­‐551-­‐9779 EQUAL OPPORTUNITY
IS THE LAW
It is against the law for this recipient of Federal financial assistance to discriminate
on the following basis:
Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief;
and
Against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA), on the basis of the
beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA
Title I-financially assisted program or activity.
The recipient must not discriminate in any of the following areas:
Deciding who will be admitted, or have access, to any WIA Title I-financially assisted program activity;
Providing opportunities in, or treating any person with regard to, such a program or activity; or
Making employment decisions in the administration of, or in connection with, such a program or activity.
WHAT TO DO IF YOU BELIEVE
YOU HAVE EXPERIENCED DISCRIMINATION
If you think you have been subjected to discrimination under a WIA Title I-financially assisted program or activity, you may file a complaint
within 180 days of the alleged violation with either:
The recipient’s Equal Opportunity Officer* for the person whom the recipient has designated for this purpose; or
The Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, DC 20210.
If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have
passed (whichever is sooner), before filing with the Civil Rights Center (see address above).
If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to
wait for the recipient to issue that Notice before filing a complaint with the CRC. However, you must file your CRC complaint within 30 days of
the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient).
If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may
file a complaint with the CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.
FOR INFORMATION OR TO FILE A COMPLAINT, CONTACT
I certify that I have been afforded an opportunity to
discuss the “EQUAL OPPORTUNITY IS THE LAW”
*The State WIA EO Officer, Harvey Andrews:
Notice with a Workforce Development Center Representative.
Iowa Workforce Development
Please be advised that the Information you provide to the Workforce
1000 East Grand Avenue
Development Center may be made available to the Federal, State or
Des Moines, Iowa 50319-0209
Local agencies and their subcontractors who administer employment
Telephone: (515) 281-8149
and training programs.
harvey.andrews@iwd.iowa.gov
Print Name: ___________________________________________
Effective Date: This notice is effective immediately and will
remain in effect until further notice.
Signature: ____________________________________________
Social Security Number: _________________________________
Date: ________________________________________________
Teresa Wahlert, Director
Equal Opportunity Employer/Program
70-8055 (09-07)
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.