Section 1:

Participant Authorization

and Consent

I consent to Work Ready Oklahoma collecting and using my information for the purposes of helping me find employment. I am aware that WRO will NOT share my personal information. *

SIGNATURE

Please agree and sign above to start

Today's Date *

Section 2: Basic Information

We need to gather information about you to determine which of our services will best help you reach your employment goals.

First Name

Last Name

Phone *

Email *

Date of birth

Street Address

City

State

Country

Country

Postal code

What is the best way to contact you? 8n5v

Text Message

Phone

Email

Do you have internet access?

Yes

No

How will you get to work? 7a63

Personal Vehicle
Bus
Walk
Friend/Family
Unsure
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Emergency Contact 3f0n

Name
Phone
Relationship

If Other valid ID, please explain 7clw

Do you have a valid ID? (select all that apply) 94w8

Driver's License

State-Issued ID

Unsure

No ID

Other

Section 3:

About You and Your Family

To understand how to plan our services and adapt our programs to better fit those we serve, we need to learn more about you.

What gender do you identify with?

Male
Female
Prefer not to say
Other
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What pronouns do you use?

He/Him/His
She/Her/Hers
They/Them/Theirs
Other
No elements found. Consider changing the search query.
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What is your race/ethnicity? (select all that apply)

Asian American

Black or African American

Native Alaskan

Native Hawaiian or Pacific Islander

Native American

White

Hispanic/Latino

Other

If other race, please list:

What language do you speak most often at home?

English
Spanish
English/Spanish Equally
Other
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How many children do you have under age 18?

Child 1 Birth Date

If applicable

Child 2 Birth Date

If applicable

Child 3 Birth Date

If applicable

Child 4 Birth Date

If applicable

Child 5 Birth Date

If applicable

Child 6 Birth Date

If applicable

How many children live with you most of the time?

Are you currently pregnant? If so, what is your due date?

Section 4: Receipt of Benefits

Do you currently receive any of these safety net services? (Select all that apply)

None of These Services

Child Day Care Assistance

Lifeline (help with paying for telephone/mobile services)

Temporary Assistance for Needy Families (TANF)

Women, Infants, and Children (WIC)

SoonerCare/Medicaid

Ticket to Work (help with getting work if you have disability benefits)

Supplemental Nutrition Assistance Program (SNAP)

LIHEAP (help with paying air conditioning/heating bills)

Free/Reduced Lunch

Early Head Start/Head Start

Public Housing/Section 8

Supplemental Security Income (SSI)

Social Security Disability Income (SSDI)

Unsure

Section 5: Education

To help us identify what jobs or training classes would be a good fit for you, we need to get some basic information about your educational and employment history.

What is the highest level of education that you have completed?

High School Diploma/GED

Certification

Some College but No Degree

Associate Degree

Bachelor's Degree

Master's Degree

Other

Section 6: Employment

To help us determine what WRO employment and training resources may be of interest to you, we need to get some information about your employment situation and/or history.

Are you currently employed?

Yes

No

IF EMPLOYED, how many months have you worked at your current job?

IF EMPLOYED, how many hours on average do you work per week?

IF EMPLOYED, What is your hourly wage?

$

IF EMPLOYED, Does your employer offer health insurance?

Yes

No

IF EMPLOYED, Does your employer offer paid time off?

Yes

No

For those not currently employed:

It is okay if you are not currently employed. We work with people who are unemployed all the time.
However, we need some information about your employment history to help us direct you to resources, training and job leads that might be a good fit for you.

How many hours are you interested in working per week?

Are you unsure about how many hours you would like to work per week?

Yes

No

What is the minimum hourly wage you need to maintain your living standards?

$

Have you previously had a full- or part-time job?

Yes

No

When was the last time you had a full- or part-time job?

How long did you work at your previous job? (Years. If less than a year, put 1)

On average, how many hours per week did you work at your previous job?

What was your previous hourly wage?

$

Were you offered health insurance at your previous job?

Yes

No

Were you offered paid time off at your previous job?

Yes

No

Any details you can tell us about your previous employment?

Section 7:

Potential Challenges to Employement

Some people experience challenges that make it hard to find or keep a good job. We work with many partner agencies that may help address these challenges.

Which of the following best describes your current housing?

Stable Housing
At risk of losing housing
Temporarily with friends/relatives
Living out of a vehicle or no steady place to reside; homeless
Other
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If other housing, please explain:

Are you currently taking any medication that would affect your ability to work?

Yes

No

Do you have any disabilities or health conditions that might affect your ability to work?

Yes

No

Will you need accommodations to participate in the workshop or when working?

Yes

No

If you need accommodations, please explain:

Can you lift 25 pounds?

Yes

No

Are you currently involved in the criminal justice system?

Yes

No

Have you ever been convicted of a felony?

Yes

No

If you have been convicted of a felony, please explain:

Have you ever been convicted of a misdemeanor?

Yes

No

If you have been convicted of a misdemeanor, please explain:

Are you currently on probation or parole?

Yes

No

Are you interested in applying for any of the services listed below? These services may be available to people who are unemployed or whose income isn’t enough to cover their bills. Some of these services may not be available where you live. (Check all that apply)

Housing Assistance

Transportation Assistance

Food Panty/Food Assistance

Legal Assistance

Medical Assistance

Help getting health insurance

Mental health services to learn how to better cope with stress and handle difficult emotions

Trauma-Related Services

Family Counseling

Parenting Workshops

Substance Use Recovery Services

Educational Training (Literacy, Nutritional, Financial)

Help paying for telephone/mobile services

Help with Child Care

Help with Energy Bills

None of these Services

Section 8:

Recruitment and Referral

Many people hear about WRO through other people, agencies or advertisements on billboards or buses. We are curious how you found out about WRO, so we can make sure more people know about us.

How did you hear about WRO? (Select all that apply)

Online Ad or Video

Direct Mail/Postal Mailer

Social Media

Word of Mouth

Billboard

Bus

Bus Bench

OKDHS

Community Partner Organization

WORKlahoma

Job fair other than WORKlahoma

Work Ready Oklahoma Website

Other

If you heard about us through other source, please explain:

What motivated you to come in to WRO today?

Getting a Job
Getting a Better Job
Getting my GED, high school equivalency or other educational services
Getting short-term vocational training
Getting a Certification
None of the Above
Unsure
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Section 9:

Photo Release

Work Ready Oklahoma - Weatherford may take photos and/or videos throughout the workshop week. Work Ready Oklahoma - Weatherford may use said photos/videos to post on its social media outlets and webpage.

I hereby grant the Work Ready Oklahoma - Weatherford permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.

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