Contact InformationName(Required) First Last Email(Required) Cell Phone #(Required)Home Phone #Work Phone #Address(Required) Street Address Apartment/Unit # (if applicable) City State Zip Code Birthdate(Required) MM slash DD slash YYYY Gender(Required) Female Male Trans Female Trans Male Gender Nonconforming Other Ethnicity(Required) Hispanic/Latino Not hispanic or latino * We are required to ask this as an organization that receives federal fundingRace(Required) American Indian or Alaskan Native Asian African American/Black Native Hawaiian or other Pacific Islander White American Indian or Alaskan Native and White Asian and White Black or African American and White American Indian or Alaskan Native and Black or African American Other Multiple Race Other (please select one)What country were you born in?United StatesAlbaniaAlgeriaArgentinaBangladeshBarbadosBrazilCambodiaCameroonCanadaCape VerdeChileChinaColombiaCosta RicaCubaDominican RepublicEcuadorEgyptEl SalvadorEritreaEthiopiaFranceGermanyGhanaGuatemalaGuineaHaitiHondurasIndiaIndonesiaIrelandItalyIvory CoastJamaicaLebanonLiberiaMexicoMoroccoNepalNicaraguaPakistanPanamaParaguayPeruPolandPortugalPuerto RicoSomaliaTogoUgandaUruguayVenezuelaVietnamOtherWhat is your primary language(Required)EnglishSpanishAhmaricAlbanianAmerican Sign Language (ASL)ArabicBanglaBengaliBosnianCape Verdean CreoleChineseDutchEweFrenchGermanHaitian CreoleHindiIndonesianItalianJapaneseKhmerLugandaMaay MaayMandingoNepaliPortuguesePunjabiRussianSomaliSwahiliTagalogTigryanaOtherUrduVietnameseWhat is your secondary language? (if applicable)EnglishSpanishAhmaricAlbanianAmerican Sign Language (ASL)ArabicBanglaBengaliBosnianCape Verdean CreoleChineseDutchEweFrenchGermanHaitian CreoleHindiIndonesianItalianJapaneseKhmerLugandaMaay MaayMandingoNepaliPortuguesePunjabiRussianSomaliSwahiliTagalogTigryanaUrduVietnameseOtherWhat is your English proficiency?(Required) Fluent Near native Advanced Intermediate Low-intermediate Beginner Family InformationNumber of adults in household(Required)Number onlyNumber of children in household(Required)Number onlyYour marital statusSingleMarriedLiving with PartnerSeparatedDivorcedWidowedIf separated/divorced and a custodial parent, are you receiving child support?YesNoHousingWhich of these options best describes your current housing situation?(Required)Shelter or transitional housingCurrently looking for housingPublic HousingSection 8 Mobile VoucherProject-Based Section 8Apartment paying market-rate rentLiving with family/friendsHomeownerShared HousingOtherIf Other Are you able to pay your rent/mortgage in full on time every month?YesNoAre you late on your rent/mortgage?YesNoHow much do you owe?EducationHighest level of education completed(Required) Some high school or less High school diploma GED Some College Vocational Degree Associates Degree Bachelor's degree Graduate Degree Country of highest level of education United States Not in the United States Please list any career goals here:What kind of educational program/training would you like to pursue?ESOLAre you interested in registering for English classes?YesNoEmployment InformationWhat is your current employment status?(Required)Employed more than full-timeEmployed full-timeSelf-EmployedEmployed part-timeCurrently looking for workWorking at homeWorking and in school/trainingHomemakerLaid off, waiting for call-backDisabledCurrently in school/trainingRetiredIncomeWhat is your monthly household income?(Required)Required for reporting purposes (numbers only)What are your current source(s) of income?(Required) Employment TAFDC/EAEDC Unemployment Food Stamps SSI/SSDI Child Support Rental Income Other Other source of income Have you received EITC/CTC/Child and Dependent Care Credit? Yes No I don't know DebtDo you have any past-due household bills? Yes No Past-due household bill amountDo you have past-due medical debt? Yes No Medical debt amountAre you carrying a balance on your credit card(s)? Yes No Credit card balance (total)Do you have past-due student loans? Yes No Student loan debt amountSCC InformationHow did you hear about Somerville Community Corporation? Agency Referral CHW Grant Program Community Event Email Employer Flyer Former First Source Participant SCALE SCC SCC Tenant SomerNova SomerViva Somerville High School Website/Social Media Other If other Agency Name(Required) Which website or social media platform?
