YWCA Metropolitan Chicago

Welcome to YWCA Metropolitan Chicago’s Economic Empowerment Institute! We are committed to helping you along the path of economic empowerment. We offer a range of programs and services. To get you to the right program, please check the box or boxes below so we know how we can best serve you. There are ten sections in total to complete, so please make sure to allocate the full time needed as you can't save your progress.

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Question - Required - What assistance are you looking for?
Please make between 1 and 5 selections from the choices below.

	Find a new or better job
	Get my finances in order
	Start or grow a business
	Learn computer skills
	Something else

Question - Not Required - If you chose "something else", please explain here:

Question - Not Required - What other services are you interested in learning more about?

	Sexual assault counseling for adults, teens & children
	Assistance w/reporting a sexual assault
	Assistance obtaining medical care after a sexual assault
	Assistance w/reporting workplace sexual harassment
	Assistance breaking free of domestic violence (outside referral)
	Assistance with housing/avoiding homelessness (outside referral)
	Assistance for pregnant teens/young parents
	Child care referral and payment assistance
	Afterschool technology programs for children ages 6-14
	Assistance obtaining health care coverage

SECTION I. CONTACT INFORMATION

Please complete all fields below

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Name:

First Required	Last Required

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Email: Required

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Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State Required	ZIP Required

Country:

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Phone Number: Required

Gender:

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Date of Birth: Required

Date of Birth:

If you respond and have not already registered, you will receive periodic updates and communications from YWCA Metropolitan Chicago.

SECTION II. DEMOGRAPHIC INFORMATION

Our program funders require us to collect certain demographic information. In addition, some of our programs have income, age, gender and geographic restrictions. We are also expected to reach certain target populations, like survivors of domestic violence, people at risk for homelessness, or returning citizens. The information you share with us is confidential. It will only be used to help you access services, improve and develop new YWCA programs and report aggregate (and not personally identifiable) data about the services provided.

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Question - Required - What is your race/ethnicity?
Please make at least 1 selection from the choices below.

	African American/Black
	American Indian/Alaskan Native
	Asian
	Hawaiian/Other Pacific Islander
	Hispanic/Latino
	Other
	White/Caucasian
	Bi-racial/Multi-racial
	Prefer not to respond

Question - Not Required - If you chose other, please specify:

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Question - Required - Do you have any special needs?

	No special needs
	Hearing impairment, requires assistance
	Visual impairment, requires assistance
	Other physical disability, requires assistance
	Requires wheelchair accessibility
	Learning disability, requires assistance
	Mental Health issues
	Drug & alcohol abuse issues
	Chronic health condition
	Limited English proficiency, requires interpreter.

Question - Not Required - What level of assistance do your require for your special needs?

Question - Not Required - If you have mental health or substance abuse issues, are you currently receiving services or treatment?

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Question - Required - What is your age group

SECTION III. VETERAN STATUS

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Question - Required - Have you served in the military?

Question - Not Required - If you answered yes, what branch did you serve in?

Question - Not Required - What is your current military status?

SECTION IV. SPECIAL CONCERNS

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Question - Required - Have you ever been convicted of a felony? (Conviction of a felony does NOT automatically disqualify you from participation in our programs.)

Question - Not Required - Of what crime were you convicted (please be specific)? What this a first offense? Only felony offense? How many years ago and how old were you?

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Are you able to pass a drug-use screening?

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Question - Required - Are you authorized to work in the US?

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Question - Required - Are you able to speak, read and understand English?

SECTION V. FAMILY/HOUSEHOLD INFORMATION

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Question - Required - Marital status/living arrangement?

Household Size: Household includes you, your spouse or domestic partner, your biological, step or adoptive children or grandchildren who live with you, other adults living with you who either provide you or depend on you for living expenses, such as food, housing, transportation and clothing.

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Question - Required - How many adults (18 years old+) live in your home?

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Question - Required - How many infants (newborn to 3 years old) live in your house?

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Question - Required - How many children (4-12 years old) live in your house?

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Question - Required - How many teens (13-17 years old) live in your home?

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Question - Required - Do you or your family members currently receive any public benefits?
Please make at least 1 selection from the choices below.

	Food Stamps/SNAP
	Childcare subsidy/CCAP
	AllKids/AllFamily
	LIHEAP
	WIC
	Section 8/Rent Subsidy/Housing Voucher/low income housing
	Medicaid
	Medicare
	Social Security/Veteran Benefits
	Other
	None

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Question - Required - Have you been homeless, lived in a shelter, or lacked housing?

Domestic or Intimate Partner Violence. We are committed to ending intimate partner violence. Because of this, we ask all clients if they have experienced intimate partner violence. Intimate partner violence includes physical assault, sexual assault, stalking, and emotional or psychological abuse. It also includes financial abuse, such as taking your paycheck and/or denying you access to your earnings and financial assets.

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Question - Required - Have you ever experienced intimate partner violence?

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Question - Required - Are you currently experiencing intimate partner violence?

SECTION VI. EDUCATION, EMPLOYMENT AND INCOME

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Question - Required - What is the highest level of education you have completed?

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Question - Required - What are your sources of income?
Please make at least 1 selection from the choices below.

	Employed full-time
	Employed part-time
	Self-employed full-time
	Self-employed part-time
	Unemployment Insurance
	Public Assistance/TANF
	Social Security/Disability
	Spouse/Partner
	Parents/Guardian
	No Income
	Other Source

Question - Not Required - If your chose other source, please specify:

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Question - Required - What is your income? (please choose the easiest way for you to calculate i.e. hourly, weekly, monthly, annually)

If you are employed:

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Question - Required - Does your current employer provide access to health Insurance?

Question - Not Required - If yes, what is your premium per pay period?

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Question - Required - Does your current employer provide paid sick leave?

Question - Not Required - If yes, how much?

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Question - Required - Does your current employer provide paid time off for vacation or errands?

Question - Not Required - If yes, how much?

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Question - Required - Are you required to work on weekends and federal holidays?

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Question - Required - Is your work schedule fixed or are you "on call" or required to different shifts each week?

SECTION VI. CAREER & WORKFORCE DEVELOPMENT SERVICES

The YWCA’s Career & Workforce Development Services team offers a range of career pathway, training and job placement services. Our ongoing funding is dependent upon our ability to track your employment success over the course of a year. If you access our Career & Workforce Development Services, we will ask you sign a form allowing us to confirm your continued employment and job performance directly with your employer. If you change positions within the year, this authorization will apply to the new position as well.

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Question - Required - What Career Services programs are you interested in accessing?
Please make at least 1 selection from the choices below.

	CATALYTIC VENTURES: CAREER FELLOWSHIP
	CONSTRUCT Career Pathway
	FIFTY PLUS program (specifically designed for women age 50 and older)
	FOOD INDUSTRY Career Pathway
	JOB CLUB a monthly group meeting where job seekers share ideas and find peer support
	LOGISTICS & DISTRIBUTION Career Pathway (for young adults 16-24)
	ONE ON ONE coaching, including career assessment, resume review and mock interviews
	SOLAR ENERGY Career Pathway
	WEEKLY JOB POSTINGS
	OTHER

Question - Not Required - If you selected OTHER, please specify:

SECTION VII. FINANCIAL WELLBEING

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Question - Required - What percentage of your income do you spend on rent/mortgage?

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Question - Required - Do you carry a balance on a credit card?

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Question - Required - Do you have a car loan/"car note"? What is the monthly payment?

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Question - Required - Do you have student loan debt?

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Question - Required - Are you able to pay your bills on time each month?

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Question - Required - Do you have a bank account?

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Question - Required - Do you have emergency savings that could last 3 months?

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Question - Required - Have you checked your credit score?

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Question - Required - Have you ever written a personal budget or financial plan?

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Question - Required - Have you ever "saved up" to buy a big ticket item?

SECTION VIII. TECHNOLOGY SKILLS & ACCESS

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Question - Required - I currently have:
Please make at least 1 selection from the choices below.

	Computer at Home
	Internet Access at Home
	Computer at Work
	Internet Access at Work
	Smart Phone
	Internet Access via Smart Phone
	Text Access via Smart Phone
	Access to Apps via Smart Phone
	Email at Home
	Email at Work
	Email via Smart Phone

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Question - Required - I currently have experience with the following programs:
Please make at least 1 selection from the choices below.

	Microsoft Office (includes Word, Excel and PowerPoint)
	Microsoft Office (includes emails, contacts and calendar)
	Social Media (Facebook, LinkedIn, Instagram, etc)
	Other

Question - Not Required - If you selected Other, please specify:

SECTION IX. BUSINESS AND ENTREPRENEURSHIP

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Question - Required - Do you have your own business, even if it is an "informal" one?

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Question - Required - Would you like to own your own business?

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Question - Required - If you own a business, would you like assistance from our Small Business Development Center (SBDC)?

SECTION X. HOW DID YOU HEAR ABOUT US?

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Question - Required - How did you hear about the YWCA? (check all that apply)
Please make at least 1 selection from the choices below.

	Church
	Current or Former Client/Member
	Community Event/Presentation
	Community Organization-not YWCA
	Counselor/Therapist
	Employer or Former Employer
	Flyer/Brochure/Poster
	Friend/Family
	Government Agency/Official
	Health Care Provider
	Newspaper/Radio/Media
	Other YWCA Program/Staff
	Sexual Assault/DV Hotline
	School
	Signage
	Telephone Directory
	Website/Internet
	Other

Question - Not Required - If you chose Other, please specify:

By clicking the submit button below, I certify that the information in this application is true and correct. I understand that falsification of any information in the application can lead to my disqualification or termination from the Economic Empowerment Institute. I also understand and certify that if I find employment from the time I begin services with the YWCA Economic Empowerment Institute, the Economic Empowerment Institute can verify such employment.

I acknowledge that the YWCA Metropolitan Chicago’s Economic Empowerment Institute, which the Catalytic Ventures Career Fellowship falls under, has provided career and workforce development coaching and training to me. This coaching and training has contributed to my ability to secure and maintain employment.

I understand that the YWCA is required to track my continued employment for one year from the date of employment and will provide ongoing coaching as needed to help me maintain and/or advance in my new position. In consideration of this, I hereby authorize my current employer to share information related to my current employment status and performance with YWCA staff, upon request. This authorization is valid for one calendar year from the date below.

In consideration, and as a condition, of my acceptance by the YWCA Metropolitan Chicago as a participant in its services and programs, I hereby waive, release and hold harmless the YWCA Metropolitan Chicago, its officers, directors, employees, representatives, and volunteers from any and all claims and actions related to or arising out of my participation in services and programs provided by the YWCA Metropolitan Chicago.

Economic Empowerment Institute Online Application