Contact InformationName(Required) First Last Email Cell Phone #(Required)Home Phone #Address(Required) Street Address Apartment/Unit # (if applicable) City State Zip Code What Ward/Neighborhood do you live in?(Required) Ward 1: Assembly Square, Cobble Hill, East Somerville, Foss Park, Inner Belt, North Point, Mystic River Ward 2: Boynton Yards, Brickbottom, Duck Village, Union Square Ward 3: Central Hill, Prospect Hill, Spring Hill Ward 4: Gilman Square, Temple Square, Ten Hills, Winter Hill Ward 5: Ball Square, Magoun Square, Porter Square Ward 6: Davis Square, Powder House Square, Tufts, West Somerville Ward 7: Clarendon Hill, Hillside, Teele Square Don't know / unsure 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)Do you identify as LGBTQIA+? Yes No Prefer not to answer What is your primary language(Required)EnglishSpanishAhmaricAlbanianAmerican Sign LanguageAmerican Sign Language (ASL)ArabicBanglaBengaliBosnianCape Verdean CreoleChineseDutchEweFrenchGermanHaitian CreoleHindiIndonesianItalianJapaneseKhmerLugandaMaay MaayMandingoNepaliOtherPortuguesePunjabiRussianSomaliSwahiliTagalogTigryanaUrduVietnameseWhat is your secondary language? (if applicable)EnglishSpanishAhmaricAlbanianAmerican Sign LanguageAmerican Sign Language (ASL)ArabicBanglaBengaliBosnianCape Verdean CreoleChineseDutchEweFrenchGermanHaitian CreoleHindiIndonesianItalianJapaneseKhmerLugandaMaay MaayMandingoNepaliOtherPortuguesePunjabiRussianSomaliSwahiliTagalogTigryanaUrduVietnameseWhat is your English proficiency?(Required) Fluent Near native Advanced Intermediate Low-intermediate Beginner Do you identify as a member of the immigrant community? Yes No Prefer not to answer Are you a US Citizen? Yes No Were you born in the United States? Yes No What is your country of origin?AlbaniaAlgeriaArgentinaBangladeshBarbadosBrazilCambodiaCameroonCanadaCape VerdeChileChinaColombiaCosta RicaCubaDominican RepublicEcuadorEgyptEl SalvadorEritreaEthiopiaFranceGermanyGhanaGuatemalaGuineaHaitiHondurasIndiaIndonesiaIrelandItalyIvory CoastJamaicaLebanonLiberiaMexicoMoroccoNepalNicaraguaPakistanPanamaParaguayPeruPolandPortugalPuerto RicoSomaliaTogoUgandaUruguayVenezuelaVietnamOtherUnited StatesYear of Arrival Highest level of education completed(Required) Less than high school graduate High School Graduate/GED 2-year college Bachelor's degree Graduate school/degree Country of highest level of education United States Not in the United States Are you a US Veteran? Yes No Active Duty Type of Driver's License None Driver's license CDL CDL with bus endorsement Do you have a physical disability? Yes No Do you have a non-physical disability? Yes No Do you have a CORI?(Required) Yes No Prefer not to state/Unkown Household InformationNumber of adults in household(Required)Number onlyNumber of children in household(Required)Number onlyAnnual household income(Required)Required for reporting purposes (numbers only)What is your source of income? Current or most recent employment informationWhat is your current employment status?(Required)Employed full-timeEmployed part-timeFull-time studentUnemployedWho is your current employer, or who was your most recent employer? What is/was your job title? What city is/was this job located in? What is/was your hourly wage?(Required)Enter $0 if you are not currently employedPlease enter a number from 0 to 199.How many hours per week?Number onlyStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY SCC InformationHow did you hear about Somerville Community Corporation? Agency Referral CHW Grant Program Community Event Community Health Worker Program Email Employer Flyer Former First Source Participant Jobs Fund Scholarship Grant SCALE SCC SCC Job Fair SCC Tenant SomerNova Somerville High School SomerViva Website/Social Media Other If other Agency Name Which website or social media platform? CertificationCertification(Required) By checking this box I certify that the information here is correct to the best of my knowledge
