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Goodwill Registration

First Name

Last Name

Email Address

Phone number

Zip Code

County

Social Security Number

Birthdate: mm/dd/yyyy

What programs/services are you interested in?

How did you hear about Goodwill Services?

Types of Internet you have access to?

Types of devices you have access to?

Citizenship Status

Race/Ethnicity

Primary Language

Gender

Marital Status

Current Housing

Available Transportation

Household Income: Select all available income

Highest Level of Education Completed

Household Size

Monthly Household Income Total

Are you currently working? .

If currently working, current wage? (If you are not working put 0)

If currently working, how many hours per week? (If you are not working put 0)

Health Insurance? .

Currently Receiving Employment Benefits

Are you a veteran? .

Identify with LGBTQ+ Community

Do any of the following apply to you?

Witnessed violence

Been a victim of violence

Been convicted of a crime

Used illegal drugs

Been a bully in the past

Currently are a bully

Currently being bullied

Currently feel in danger at home

Been in a gang (currently or in the past)

Been in a fight

Been emotionally abused

None

Prefer not to answer

Health Barriers (Select all that apply)

Are you currently experiencing mental health challenges that are affecting your ability to work, attend school, or complete daily tasks?

Situational Barriers (Select all that apply)

Are you currently on Probation/Parole?

DOC ID# (enter n/a if no DOC number) .

I agree to opt-in to mass communication from MERS Missouri Goodwill Industries.

I hereby authorize MERS Missouri Goodwill Industries to disclose my personal identifying information to obtain a consumer report for employment verification. This disclosure may be revoked by me at any time, except to the extent of the information that has already been disclosed. A request to revoke consent for disclosure must be submitted in writing to your program supervisor. If you agree to the statement above, please sign below.

Signature