subject_line
Join the AbilIT Team
First Name
*
Middle
Last
*
Suffix
DOB
*
+
Gender
*
Female
Male
Marital Status
*
Single
Married
Widow/Widower
Have you ever received services from Melwood?
*
Past
Current
No
Race
*
African-American
Asian
Bi-Racial
Caucasian
Hawaiian or Pacific Islander
Hispanic
Multi-Racial
Native-American
Other
Street
*
City
*
State
*
Zip Code
*
Phone
*
Email Address
*
Citizenship (Name of Country)
*
Are you legally authorized to work in the United States?
*
Yes
No
Guardianship
Do you have a legal guardian? If yes, complete the following:
*
Yes
No
Guardian's Name
Guardian's Contact Number
Relationship to Applicant
Guardian Address
Email
Military Service
Have you served in any branch of the US Armed Forces?
*
Yes
No
Are you a Veteran?
*
Yes
No
Are you a service disabled veteran?
*
Yes
No
Medical
Do you have a disability?
*
Yes
No
Primary Disability
*
Physical (Mobility and/or Health)
Neurodevelopmental
Mental Health
Sensory (Blind, Hearing Impaired)
N/A
Secondary Disability
Physical (Mobility and/or Health)
Neurodevelopmental
Mental Health
Sensory (Blind, Hearing Impaired)
N/A
Tertiary Disability
Physical (Mobility and/or Health)
Neurodevelopmental
Mental Health
Sensory (Blind, Hearing Impaired)
N/A
Are you a service disabled veteran?
*
Yes
No
Do you need accommodations? Please select type:
*
None
American Sign Language
Computer application or adaptation
Language interpreter
Other
Are you able to work independently with minimal supervision:
*
Yes
No
Are you able to ask for assistance if necessary?
*
Yes
No
Do you need accommodations?
*
Yes
No
If you answered yes, please describe accommodations needed:
Training and Resources
Training
Highest Level of Education:
*
Did not complete High School
High School Diploma or GED
Trade School
Associate's Degree
Bachelor's Degree
Masters
Certificate/License (include License Number):
Certificate/License (include License Number):
Government or State Assistance
Are you currently receiving government assistance? If yes, complete the following:
*
Yes
No
Assistance you receive: Check all that apply.
SSI
SSDI
Social Services
Medicare/Medicaid
Ticket to Work
Other
Other
Are you currently receiving services from any other agency?
*
No
Yes (if yes, list agencies)
Yes (if yes, list agencies)
Are you currently receiving monetary benefits from any other agency?
*
No
Yes (if yes, list agencies)
Yes (if yes, list agencies)
Were you referred by another agency for Melwood programs or services?
*
Yes
No
Agency Name
Contact Person
Agency Address
Email
Transportation
What type of transportation will you use to get to/from program or work? Circle all that apply
What type of transportation will you use to get to/from program or work? Check all that apply.
*
Car Pool
County Commuter Bus
Metro
MetroAccess
Metro rail
Personal Vehicle
Other
Other