NeCCESS Intake FormPlease complete and submit the application form below to be reviewed for the program. GENERAL INFORMATION Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * EMERGENCY CONTACT INFORMATION Name First Name Last Name Phone (###) ### #### Email PROGRAM REGISTRATION For which program are you applying, check all that apply. Women in Transition (WiT) Adult Diploma Program (ADP, GED, Ohio Options) Supply Chain, Logistics Technology, and Warehouse Training Microsoft Office (Beginners Class) Other If other, please specify the program: BACKGROUND INFORMATION Please Check Highest Level of Education Attained/Completed Some High School HS Diploma/GED Associates Degree Bachelor's Degree or Higher Do You Hold Any Professional/Technical Certification(s) or License(s)? Yes No If Yes, Please List: DEMOGRAPHIC INFORMATION Which of the following most accurately describes you? Choose as many as you'd like. * Female Male Non-binary Transgender Intersex I'd prefer not to say Other Age Range * 18 - 22 23 - 29 30 - 39 40 - 49 50 + Current Employment Status * Full-Time Employment Part-Time Employment Unemployed Student Retired Are you eligible to receive TANF benefits? * Yes No If yes, are you currently receiving TANF benefits? Yes No Are you currently receiving any assistance with managing the costs of food and/or health insurance? * Yes No PERSONAL PROFILE Please respond to the following questions in 75-80 words each. (Responses will be reviewed for thoughtful reflection and will not affect your registration.) What is your motivation for participating in this program? Have you ever been convicted of a felony? (Felony convictions are not considered a barrier to opportunities and access to training.) If yes, explain: How did you hear about the OHCDC/TRI-C Access Center? * Friend Family Member OIBC Church Announcement/Newsletter Community Event OHCDC Staff Member or Website TRI-C Staff Member or Website Media (radio/news) Social Media (Facebook, Instagram) Online Search (such as Google) Unite Us referral Other: Media Release * I give Olivet Housing & Community Development Corporation (OHCDC) and/or Olivet Institutional Baptist Church (OIBC) permission to record the image and/or voice of the person named below, and I grant OHCDC/OIBC all rights to use sound, still or moving images in any medium for educational, promotional, advertising, or other purposes to support the mission of OHCDC/OIBC. I agree that all rights to the sound, still or moving images belong to OHCDC/OIBC. I agree I do not agree By clicking the "Submit" button below you affirm/agree/attest that all of the information in this form is true. Thank you!
