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Workforce Villages Program Application
Today’s Date
*
Your Name
*
Your Name
First
First
Middle
Middle
Last
Last
Phone
Preferred Name (if different from above)
Email
*
Social Security Number
*
Date of Birth
*
Phone Number
*
Do you have a cell phone?
*
Yes
No
Cell phone type:
*
Personal cell phone
Government cell phone
Your preferred contact method
*
Phone call
Text
Email
Were you referred to us by another agency?
*
Yes
No
If yes, which agency referred you?
*
If you were not referred by an agency, how did you hear about Workforce Villages?
*
Have you ever been a client of the Workforce Villages previously known as Employment Bridge?
*
Yes
No
When you left the Workforce Villages Program was your exit
*
Successful
Unsuccessful
Please tell us more about your successful Workforce Villages exit:
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Do you have $750 in savings?
*
Yes
No
Why have you become unhoused again?
*
What have you learned?
*
Why should you be reconsidered? (supporting documents recommended)
*
If in recovery, how is it going? How are you obtaining sobriety support, if necessary?
*
If sobriety was an issue, please provide documentation regarding your treatment.
*
Please tell us more about your unsuccessful Workforce Villages exit:
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Do you have $500 in savings?
*
Yes
No
Why were you exited?
*
What have you learned?
*
Why should you be reconsidered? (supporting documents recommended)
*
If in recovery, how is it going? How are you obtaining sobriety support, if necessary?
*
If sobriety was an issue, please provide documentation regarding your treatment.
*
Current Housing
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Are you currently experiencing homelessness?
*
Yes
No
If yes, where are you staying?
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Shelter
Friend
Family
Street
Other
Other
Have you ever been unhoused before?
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Yes
No
If yes, how many times have you been unhoused?
*
Address
*
City
*
State
*
Zip Code
*
What was your prior living situation before becoming unhoused?
*
When was the last time you had a lease in your name?
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Have you ever been evicted?
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Yes
No
If you have been evicted, when?
*
Demographics
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Are you in HMIS?
*
Yes
No
Unknown (explain)
Unknown (explain)
If yes, HMIS #
*
Ethnicity
*
Indigenous
Asian
Black
Hispanic/ Latino
White
Native Hawaiian/ Islander
Other
Other
Gender
*
Female
Male
Nonbinary
I choose not to say
Other
Other
Are you a part of the LGBTQ+ community?
*
Yes
No
I choose not to say
Are you a veteran or active military?
*
Yes
No
Are you receiving disability benefits?
*
Yes
No
Are you fleeing a domestic violence situation?
*
Yes
No
Do you have any dependents?
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Yes
No
If yes, how many dependents do you have?
*
What is the highest degree that you have completed?
*
No degree
GED
High School Diploma
Trade School/ Associates
Bachelor’s Degree
Master’s Degree
Doctorate
If no degree, what is the highest grade level you completed?
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8th grade
9th grade
10th grade
11th grade
12th grade
Do you have a Driver’s License?
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Yes
No
What is your primary form of transportation?
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Public transportation
Your own car
Shared car
Do you have substance use challenges?
*
Yes
No
If yes, what type (gambling, alcohol, drugs, etc.)
*
If these are former challenges, how long have you been in recovery?
*
Employment & Benefits
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Are you receiving SNAP/ EBT benefits this month in Arizona?
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Yes
No
If yes, how much?
*
Are you receiving WIC benefits this month in Arizona?
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Yes
No
If yes, how much?
*
Employer Name
*
Employer Address
*
Employer Address
Employer Address
Employer Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
What city do you work in?
*
Your work cross streets
*
Your start date
*
Your hourly rate of pay
*
Benefits offered? (even after 90 days)
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Yes
No
How often do you get paid?
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Weekly
Twice a month
Biweekly / every other week
Monthly
Is your position:
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Temporary
Permanent
If temporary, is it temp to hire?
*
Yes
No
Can you provide proof?
*
Yes
No
Do you have a copy of your last paycheck?
*
Yes
No
If no, when will you receive one?
*
Do you have any other income? (SSI, SSDI, etc.)
*
Yes
No
If yes, what type?
*
Are you on AHCCCS (state health insurance)?
*
Yes
No
If yes, which plan?
*
Arizona Complete Health
Arizona Complete Health – SMI
Banner University Family Care
Care 1st
DCS/ CMDP
Magellan Complete Care
Mercy Care Plan
Mercy Care Plan – SMI
Steward Health Choice Arizona – SMI
Steward Health Choice Arizona
If no, do you have any other insurance?
*
Yes
No
If you do have other insurance, is it:
*
Employer-based
Private pay
Living Arrangement & Background
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Do you have a pet?
*
Yes
No
If yes, are they registered and trained as a support animal?
*
Yes
No
Would there be any occasion for your to have a guest in your room during the duration of the program?
*
Yes
No
If yes, please explain:
*
Do you have any existing medical conditions/scheduled surgeries/doctors’ appointments that will interfere with your work for the duration of the program?
*
Yes
No
If yes, please explain:
*
Are you willing to complete a background check for the Workforce Village Team to assist you with possible future challenges with employment or housing?
*
Yes
No
Do you have any criminal background such as outstanding warrants / past or current felonies or misdemeanors?
*
Yes
No
If yes, please explain:
*
Do you have any upcoming court dates within the duration of the program?
*
Yes
No
Are you on probation or parole?
*
Yes
No
If yes, what is the name and number of your probation or parole officer?
*
If yes, what are your probation or parole requirements?
*
Do you have any substantial time off for work planned for the duration of the program, such as vacation?
*
Yes
No
If yes, please explain:
*
Finances
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Are any of your wages being garnished? (i.e. court fees, medical bills, child support, alimony, etc.)
*
Yes
No
Do you have any other outstanding debts?
*
Yes
No
Garnished wages $/ month
*
Legal fees $/ month
*
Car payment $/ month
*
Car insurance $/ month
*
Storage unit $/ month
*
Student loans $/ month
*
Medical bills $/ month
*
Health insurance $/ month
*
Cell phone $/ month
*
Credit card $/ month
*
If you have existing credit cards, by completing the intake into the Workforce Villages Program, do you agree to not use your credit cards without authorization during your program stay?
*
Yes
No
Do you have a bank account? (Chime, NetSpend, CashApp, Wisely, etc. are not eligible for a savings and/or checking account)
*
Yes
No
If yes, which one(s)?
*
Are you willing to use and/or open a Bank account strictly for savings for the Workforce Villages Program within the next 10 days? (Client has full control over account)
*
Yes
No
Do you need assistance in finding a financial institution or opening an account?
*
Yes
No
Have you ever budgeted money before?
*
Yes
No
What is your biggest concern about budgeting?
*
In addition of putting 80% of your paychecks into savings, are you willing to put 100% of any tax refunds, military payments, stimulus checks or social security benefits you are receiving or may receive into savings while in this program?
*
Yes
No
Are you committed to sharing information throughout this process, regarding losing a job, not maintaining sobriety, etc.?
*
Yes
No
Do you feel comfortable with showing your Workforce Villages Team Member your bank balances, account activity, and paystubs weekly?
*
Yes
No
Are you willing to meet with our Workforce Village Team weekly to work on your goals?
*
Yes
No
Please upload your employment offer letter & paystub(s)
Drop a file here or click to upload
Choose File
Maximum file size: 516MB
If you are human, leave this field blank.
Submit
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About Us
Our History
Success Stories
Financial Information
Careers
Our Team
Board of Directors
Get Involved
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Donate
Expand child menu
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Donate to SJW
Donate Items
Arizona Charitable Tax Credit
Volunteer
Workforce Villages for Business
Events
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Hike for Hope
2024 Feeney Winthrop Benefit Concert
Be the Impact
News
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