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Social Coop Spring 2023 Application Form
Please complete this form to apply for CIDA’s Social Coop Workforce Development Program. If you need help filling out this form, please contact 718-224-8197 Ext. 3
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* Indicates required question
Email
*
Your email
[Applicant Information] First Name
*
Your answer
[Applicant Information] Last Name
*
Your answer
[Applicant Information] Date of Birth
*
MM
/
DD
/
YYYY
[Applicant Information] Email Address
*
Your answer
[Applicant Information] Cell Phone Number
*
Your answer
[Applicant Information] Address
*
Your answer
Have you (the applicant) worked in a paid position?
*
Yes
No
I am applying for (check one):
*
Office/Retail Skills Training Program
Art Initiative Training Program
I am able to read and understand texts in (check one):
*
High School level or above
Middle School Level (6-8th grade)
3-5 grade
Below 3rd Grade/Unable to read
I don't know
Required
I receive services from (check all that apply):
*
ACCES-VR
OPWDD
Independent Living Center
None of above
Other:
Required
I receive government benefits (check all that apply):
*
Social Security Supplemental Income (SSI)
Medicaid Benefits
SNAP
HEAP
None of the above
Other:
Required
Briefly explain the things that you need help with (e.g. transportation, understanding instructions etc.)
*
Your answer
Parent/Guardian Name
*
Your answer
Parent/Guardian's Telephone Number
*
Your answer
Parent/Guardian's Email Address
*
Your answer
Parent Address (if different from applicant's)
Your answer
Name of person who completed this form:
*
Your answer
Submit
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