ONE CITY UNITED'S
MOMENTUM
Pre-Enrollment Form
MOMENTUM: Pre-Enrollment Form
Please complete all fields below.
Personal Information
Full Name *
Address
Email
Phone *
Gender
- Please select -
Male
Female
ETHNIC STATUS
- Please select -
White
African American
Hispanic/Latino
Asian
Bi-Racial
Alaskan Native
Pacific Islander/Hawaiian
Native American
Other
Military Service
Are you a U.S. Veteran?
- Please select -
Yes
No
Work
What kinds of jobs are you looking for or interested in doing? Are you interested in an internship?
Where have you applied to work in the last 2 weeks? If not, why?
Employment Restrictions
Is there anything physically or legally prohibiting you from employment?
Work History
When was the last time you worked? Where?
Additional Details
Do you have your driver’s license?
- Please select -
Yes
No
Current Programs & Services? (Church? DOC Education? Mental Health/Substance Treatment? Recovery Groups?)
How did you hear about Momentum?
What drives you to be successful? What would cause you to make it six weeks?
SUBMIT APPLICATION