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What We Offer
How You Can Help
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- Accessible Contact Options
- West Virginia Women Work Media Kit

Who We Are
What We Offer
How You Can Help
Resources
Contact Us
- Accessible Contact Options
- West Virginia Women Work Media Kit

Where did you learn about Step Up for Women? *

If you selected "Other", please specify: *

If you selected "In Person Event", please specify: *

If you were referred by a previous graduate, what is their name?

Step Up site closest to you: *

Name *

First

Last

What is your preferred name/nickname?

If you go by a name other than your given name please tell us here

Date of Birth *

What are the last 4 digits of your social security number? *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What county do you currently live in? *

Example: Kanawha, Lincoln, Putnam, Clay

Phone Number *

Cell Phone

Personal Information

Do you currently have a driver's license? *

Yes
No
Yes, but it's suspended

Do you own a car and is it available for personal use? *

Yes
No

If no car, how do you plan on getting to class/work? *

Are you currently married?

Yes currently married
No never married
Separated
Divorced

Do you have dependents? *

Yes
No

How many dependents do you have? *

Number of people in household? *

Are you willing and able to obtain full time employment at the conclusion of training? *

Yes
No (please explain below)

Explain why you are not able to obtain full time employment at the conclusion of training *

Do you currently or are you scheduled to receive Unemployment Compensation? *

Yes
No

If yes, when will your UC benefits end? *

Check any that apply to you: *

Single parent
Displaced homemaker
Head of Household
Veteran
None of the above

Check any forms of assistance you currently receive: *

Snap
WV Works/TANF
SSI
SSDI
Veteran Benefits
Medicaid
Section 8 rental assistance/HUD
WIC
None of the above

Current Estimated Yearly Household Income: *

0 - 10000
10000 - 25000
25000 - 50000
50000 +

Are you currently in recovery from substance abuse?

Yes
No
Formerly in recovery
I would like more information about getting help for substance abuse

Have you been vaccinated against Covid 19? *

Yes
No

Would you be willing to be vaccinated against Covid 19 for employment? *

Yes
No

Do you have a physical or mental disability that requires accommodations that you must consider when looking for a job? *

Yes
No

If yes, please explain: *

Have you ever been convicted of a felony? (Your answer will not impact the outcome of your application) *

Yes
No

What were the charges? *

Did your conviction result in incarceration? *

Yes
No

Have you ever been convicted of a misdemeanor? (Your answer will not impact the outcome of your application) *

Yes
No

What were you charged with? *

If on parole can we speak to your parole officer? *

Yes
No

If yes, be sure to provide name and number during your interview

Career Goals and Qualifications

Why are you interested in enrolling in the Step Up For Women training program? *

Education

Do you have your High School Diploma or GED? *

Highschool Diploma
GED
No

If no, highest grade completed? *

If no, are you interested in obtaining your GED?

Yes
No

Check any of the following Math levels completed while in school:

Basic math
Algebra
Geometry
Trigonometry
Other

What other math levels have you completed?

List all vocational technical courses completed:

Include course title, year completed, and school.

Have you taken any courses since high school?

Yes
No

List all degrees and professional/vocational certificates, year received, and school:

Employment History

Current Employment Status: *

Employed full time
Employed part time
Unemployed
Student

If currently employed what is your hourly wage? *

What do you make an hour? Example $10.00

Employment history: Include title and wages for the past five years *

List most recent jobs first.

Any additional information:

Provide any other information that you feel makes you a good candidate to participate in the Step Up for Women training program.

Technology

Do you have reliable access to a computer you can use for class? *

Yes
No

Do you have reliable access to the internet for class? *

Yes
No

Optional (We will use this data for grant reporting. All data will remain anonymous and will only be used for this purpose.)

Please indicate how you identify yourself: The following items are OPTIONAL. No information you provide in this section will be used in a discriminatory manner.

American Indian or Alaska Native (including all Original Peoples of the Americas)
Asian (including Indian subcontinent and Philippines)
Black or African American, not Hispanic (including Africa and the Caribbean)
Native Hawaiian or Other Pacific Islander (Original Peoples)
White, not Hispanic (including Middle Eastern)
Hispanic or Latino
Two or More Races (not Hispanic or Latino)
Other
Prefer not to answer

Check the boxes for any barriers you are currently facing and would like resources to overcome.

Lack of or not enough food
Childcare
Homelessness
Addiction(drug or alcohol)
Domestic Abuse
Transportation
Other(please explain below)

List any other barriers you are currently facing.

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternately, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *

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