Let’s get to know you… – Project REBUILD, Inc.

Name *

First

Last

Phone Number *

Email *

Gender *

Male
Female
Prefer not to answer

Prounouns

He/Him
She/Her
They/Them

Your Ethnicity? *

Hispanic or Latino
Not Hispanic or Latino

Your Race? *

Primary Language *

English
Spanish
French
Other

Your Marital Status *

Do you identify as LGBTQ? *

Yes
No
Prefer not to answer

Citizenship *

I am *

Registered to Vote
Not eligible to Vote
Eligible to Vote but not registered

Are you registered with Selective Service? *

I am registered
I am a male, over the age of 18, but not registered
Not 18 yet
A female, not required to register

I have a high school diploma or GED *

Yes
No

I currently am living *

Have you ever been in foster care? *

Yes
No

Have you been homeless in the last year? *

Yes
No

Are you a parent? *

Yes
No
Currently Pregnant

Are you a single parent? *

Yes
No

If you are a parent, please list age(s) of child(ren)

Do you need child care assistance? *

Yes
No

Are you caring for an adult or relative with a disability? *

Yes
No

Do you need reliable dependent care? *

Yes
No

Are you a veteran? *

Yes
No
Spouse of a veteran

Do you use alcohol? *

Yes
No

Do you use drugs? *

Yes
No

Do you have reliable transportation? *

Yes
No

Do you or a family member receive any of the following: *

Check all that apply

Education Status *

The last school you attended was *

The last day you attended was *

Are you on target to graduate? *

Yes
No
Not sure
Not Applicable

Do you have a learning disability? *

Yes
No

Do you have an IEP in school? *

Yes
No

Do you have any volunteer experience? *

Yes
No

Have you filled out a job application before? *

Yes
No

Have you made a job resume? *

Yes
No

Are you currently working or have you worked in the last 6 months? *

Yes
No

Do you have previous work experience? *

Yes
No

If you answered yes to above question: who was your most recent employer?

What month did you start in?

What month did you end in?

How many hours did you work on average?

What was your hourly wage?

Do you have any physical disabilities that keep you from working? *

Yes
No

Do you know how to use a computer or chrome book? *

Yes
No

What computer software are you familiar with? *

Select all that apply

Do you have a business/personal relationship with any individual who is a: *

Local elected official (mayor or county commissioner)
Workforce development board member or subcommittee member
WIOA executive, supervisor, or employee
Ohio Means Job center employee, partner employee, or WIOA sub-recipient or contractor
CDJFS or other county employee
None of the above

What are your goals to help you become independent? *

Select all that apply

What are the steps you need to take to achieve your goals? *

What is your primary career goal? *

If other, please list.

Are you on probation or parole *

Yes
No

Do you have community service to complete? *

Yes
No

If you answered yes, we are an approved Community Service site through the Canton Municipal Court. Talk to us because we can submit your unpaid Mental Toughness hours for credit.