Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Ethnicity

European American

African American

Native American

Hispanic

Asian

Other

Are you a United States Citizen? *

Yes

No

If no, can you provide proof of residency? *

Yes

No

Are you currently legally authorized to work? *

Yes

No

If no, are you in the process of securing work authorization? *

Yes

No

Will you be able to provide the following forms? *

Yes

No

US Social Security Card *

Yes

No

US Green Card *

Yes

No

Driver's License *

Yes

No

Choose highest grade completed: *

4

5

6

7

8

9

10

11

12/GED

Vocational Training

Junior College

College

Graduate School

Did you receive a certificate or diploma from a college or training facility? *

Yes

No

Do you have a criminal history? *

Yes

No

Have you ever been convicted of a felony and/or served time in the past? *

Yes

No

Are you willing to take a drug test? *

(answering "No" will not disqualify a person from becoming a Jobs for Life student)

Yes

No

Check all that apply: *

Unemployed

Full-time job

Part-time job

Self-Employed

Retired

Are you a current recipient of government assistance? *

Yes

No

Current Marital Status: *

Married

Single

Divorced

Separated

Widowed

Housing arrangement: *

Rent

Own

Homeless

Other

Will you need childcare during your Jobs for Life training? *

Yes

No

Will you need transportation during your Jobs for Life training? *

Yes

No

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Start Date:

MM

DD

YYYY

End Date:

MM

DD

YYYY

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Start Date:

MM

DD

YYYY

End Date:

MM

DD

YYYY

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Start Date:

MM

DD

YYYY

End Date:

MM

DD

YYYY

How did you hear about JfL:

Card in the mail

Flyer on my door

Friend

Other

Yearly income: *

This information is kept confidential and used for funding purposes only.

$0-$15,060

$15,060-$20,440

$20,440-$25,820

$25,820-$31,200

$31,200-$36,580

$36,580-$41,960

$41,960-$47,340

$47,340-$52,720

$52,720+

JfL Applicant Signature:

I hereby authorize that STEP may use photos, videos, or other digital images taken of me or my child(ren) at a Jobs for Life class or event to promote the ministries of STEP.

First Name

Last Name

Date:

MM

DD

YYYY

Child's Name *

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Child's grade: *

Kindergarten

1st Grade

2nd Grade

3rd Grade

Boy or girl:

Boy

Girl

Parent's Name: *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Phone *

(###)

###

####

Is your child reading on or below grade level? *

On grade level

Below grade level

What is the name of your child's teacher?

First Name

Last Name

Name:

First Name

Last Name

Phone:

(###)

###

####

Name: *

First Name

Last Name

Phone: *

(###)

###

####

Name:

First Name

Last Name

Phone:

(###)

###

####

Name of child's personal physician:

First Name

Last Name

Physician's phone number:

(###)

###

####

Does your child have any type of learning disability?

Yes

No

Does your child have any food allergies? *

For preferences, please select "No" and list preferences below.

Yes

No

Total annual household income: *

Including wages/salaries, social security income, pensions, dividends/interest, SSI, etc. (This information is kept confidential and used for funding purposes only.)

$0-$15,060

$15,060-$20,440

$20,440-$25,820

$25,820-$31,200

$31,200-$36,580

$36,580-$41,960

$41,960-$47,340

$47,340-$52,720

$52,720+

Parent Signature - photo and liability release *

By enrolling my child in the Victory Reading Program, I acknowledge that STEP may use my child’s photo or other digital images to promote the Victory Reading Program and the STEP ministries. I understand that all activities entail potential risk of harm, bodily injury, or illness. I voluntarily agree to accept any risk of harm, injury, or illness (including COVID-19) arising from my child’s (or the child whom I am registering for this program) participation in this program including those that may arise while transporting my child (or the child whom I am registering for this program) to and from any associated activities.  In the event of an injury requiring medical attention, I grant permission to the supervising Director(s) or staff (including volunteers) to attend to my child. If the injury warrants further medical attention, every effort will be made to contact me to receive my specific authorization before action is taken. If efforts to contact me are unsuccessful, I grant permission for necessary medical treatment to be given. I agree to accept full responsibility for costs of medical care and transportation incurred in such an event.

First Name

Last Name

Date:

MM

DD

YYYY