Name * First Name Last Name Email * Mobile Phone (###) ### #### Okay To Text? Yes No Address Line 1 * Address Line 2 City * State * Zip Code * Candidate Type Young Adult Reentry Recovery Hardship Veteran Other Support Services Needed Resume and cover letter assistance Interview preparation or coaching Skill development or training interests Access to Transportation or Work Attire Financial Planning or Budgeting Assistance Mentorship Program Trades Apprenticeship Work Experience Training Under Employed / Need Better Job Referring Organization * AA Referral A Sense of Home AJCC ARC Anaheim Workforce Connection Barry Vince Big Brother Big Sisters Blue Coast Breakaway Recovery Casa de Amparo Chrysalis Covenant House HIRE Lighthouse Mass Liberation Miracles for Kids MPF Institute Motive Workforce OC Recovery Collab Orangewood Pacific Gateway Pathways PH Wellness Project Kinship Santa Ana Workforce San Diego Workforce Stars & Stripes The Purpose of Recovery Tilly's Life Center TLH Working Wardrobes Young Lives Redeemed Other AA Referral (Other) Please List Org Are You in a Program with Another Organization? No Yes Type of Work You Are Looking For * Date of Birth * MM DD YYYY Age 0-17 18-24 25-29 30-39 40-49 50-59 60-69 70+ Gender * Female Male Nonbinary/Gender Noncomforming Trans Male Trans Female Prefer Not to Say Other Primary Language Spoken English Spanish Bilingual English/Spanish Vietnamese Mandarin/Chinese Korean Japanese German French Ethnicity American Indian or Alaska Native Asian Indian Black or African American Chamorro Chinese Filipino Japanese Korean Native Hawaiian Other Asian (Pakistani, Cambodian, Hmong, etc. Other Pacific Islander Samoan Vietnamese Non-Hispanic, Latino, or Spanish Origin Mexican, Mexican American, Chicano Puerto Rican Cuban Other Hispanic, Latino, or Spanish origin White (German, Irish, English, Italian, Lebanese, Egyptian, etc.) Other/Unknown Highest Level of Education GED High School Degree AA Degree Bachelor's Degree Master's Degree Currently in School Some College None Income Level Low-income Moderate-income Not Applicable Last 5 of Social * Please enter the last 5 digits of your Social Security Number. Single Parent No Yes Disability Diseases/Illness Hearing Disability Visual Disability Ambulatory Disability Self-Care Disability Mental Disability Learning Disability Development Disability Other Physical Disability None Veteran No Yes System Impacted Yes No On Probation Prefer Not to Answer Former Foster Youth No Yes Housing Status Rent/Own Live with Family/Friends Sober Living/Treatment Home Transitional Home Staying in a Shelter Currently Unhoused Other Driver License Yes - Regular Class C No In the Process of Getting One I Have Class B I Have Class A Do You Have an ID Card? California Driver's License California ID Other State Drivers License Other State ID Working on getting ID No ID, Need help getting one Do You Have Reliable Transportation? I Have a Car Will Use Public Transportation Can Get a Ride Will bike Other Do you have a computer Yes No I Have a Smartphone or Tablet Employment Status Working Full Time Working Part Time Self Employed Unemployed Retired Compensation Type Hourly Salary Desired Compensation Job Location Preference Onsite Remote Only Hybrid List All Cities You Can Work For Type of Work You Are Looking For Shift / Schedule Preference Day Shift 8am-5pm Afternoon Shift 1pm-9pm Night Shift 8pm-5am I am flexible on work hours Can work weekends Can't work weekends Holidays On Call Job Function Interest Accounting/Finance Business Development Manufacturing Engineering Management Information Technology/Computer Administrative Healthcare Sales Customer Service Transportation Health & Wellness Construction Hospitality Marketing Public Relations Child Development Security Human Resources Art/Creative Teaching Design Union Job I have NO Idea! What Online Job Sites Are You Signed Up With? Indeed LinkedIn Monster Career Builder CalJobs - EDD Zip Recruiter Glassdoor Other LinkedIn http:// Any other info you like us to know Upload Resume Option Yes, I have attached it No, I need help creating one Right to Work in the U.S. Status - Select One: * Yes, I am a U.S. citizen Yes, I am a permanent resident (green card holder) Yes, I have a valid work permit (e.g., DACA, asylum, refugee status, etc.) Yes, I am authorized to work in the U.S. under another status No, I am not currently authorized to work in the U.S. Photo & Media Release Consent * I give Merge Opportunities permission to use photographs or video recordings of me taken during program activities for promotional, educational, or informational purposes (such as on our website, social media, printed materials, or reports). Please select one: Yes, I consent to be photographed/recorded and for my image to be used. No, I do not consent to be photographed/recorded. Thank you!
