COVID STATUS HAVE YOU SUFFERED AN ADVERSE FINANCIAL CONSEQUENCE AS A RESULT OF YOU OR A MEMBER OF YOUR HOUSEHOLD BEING AFFECTED BY COVID19? IF YES, HAS THAT FINANCIAL LOSS AFFECTED YOUR ABILITY TO ENTER

RAPID RE-EMPLOYMENT APPLICATION
DATE *

Month Day Year
Date
Name *

First Name Last Name
ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PHONE *
BIRTHDATE *

Month Day Year
Date
SS# *
ARE YOU A HAMILTON COUNTY RESIDENT? *
ARE YOU ELIGIBLE TO WORK IN THE US? *
COVID STATUS

HAVE YOU SUFFERED AN ADVERSE FINANCIAL CONSEQUENCE AS A RESULT OF YOU OR A MEMBER OF YOUR HOUSEHOLD BEING AFFECTED BY COVID19? IF YES, HAS THAT FINANCIAL LOSS AFFECTED YOUR ABILITY TO ENTER EMPLOYMENT OR TO MAINTAIN EMPLOYMENT?
IF YES, PLEASE SPECIFY HOW. *

HOUSEHOLD MEMBERS (INCLUDE YOURSELF) *

	NAME	DATE OF BIRTH	NAME	DATE OF BIRTH

HOUSEHOLD INCOME FOR THE PAST 30 DAYS *

	AMOUNT(S)	INCOME SOURCE(S):
Income Amt/Source 1
Income Amt/Source 2
Income Amt/Source 3
Income Amt/Source 4
Income Amt/Source 5
Income Amt/Source 6

WORK HISTORY – UP TO 5 YEARS (START WITH THE MOST RECENT JOB) *

	Company/ Job Title	Date Range Employed/Hourly Pay
Entry 1
Entry 2
Entry 3
Entry 4
Entry 5

WHAT PREVENTS YOU FROM GETTING OR KEEPING A JOB? (MARK ALL THAT APPLY) *

CHILDCARE CITIZENSHIP QUALIFICATIONS/SKILLS CLOTHING COMPUTER SKILLS STAY WITH RELATIVE CRIMINAL DISABILITY NO BARRIERS HOUSING IEP NO RESUME MEDICAL/HEALTH Other
EMAIL ADDRESS *
example@example.com
ALTERNATE PHONE
GENDER *
RACE *

ASIAN BLACK/AFRICAN AMERICAN HAWAIIAN/PACIFICA ISLANDER HISPANIC MULTI-RACIAL Native American/ALASKAN NATIVE CAUCASIAN/WHITE Other
EMERGENCY CONTACT NAME *
EMERGENCY CONTACT PHONE *
EMERGENCY CONTACT EMAIL
example@example.com
RELEASE OF INFO AUTHORIZATION
I blanks* UNDERSTAND THAT THE RAPID RE-EMPLOYMENT PROGRAM NEEDS TO RECEIVE INFORMATION CONCERNING MYSELF AND/OR MY FAMILY AND IS ASKING FOR COOPERATION IN THIS PROCESS. I DO GIVE MY CONSENT TO THE CINCINNATI-HAMILTON COUNTY COMMUNITY ACTION AGENCY, URBAN LEAGUE OF GREATER SOUTHWESTERN OHIO, EASTER SEALS, AND CINCINNATI WORKS TO RELEASE THE INFORMATION FOR THE PURPOSE OF CLIENT ASSISTANCE, ETC. AND UNDERSTAND THAT MY INFORMATION MAY BE SHARED WITH PARTICIPATING AGENCIES. I UNDERSTAND THIS CONSENT FOR RELEASE OF INFORMATION SHALL REMAIN IN EFFECT FOR ONE YEAR, UNLESS I REVOKE MY CONSENT TO THIS AGREEMENT.
EMPLOYMENT CONFIRMATION
I,blanks*,AGREE TO INFORM THE RAPID RE-EMPLOYMENT PROGRAM UPON OBTAINING EMPLOYMENT. I GIVE PERMISSION TO THE RAPID RE-EMPLOYMENT PROGRAM TO VERIFY MY EMPLOYMENT STATUS, INCLUDING PAY AND BENEFIT INFORMATION THROUGH DIRECT ACCESS WITH MY EMPLOYER.
I DECLARE THE INFORMATION SUBMITTED ON THIS APPLICATION IS TRUE AND CORRECT.
CLIENT SIGNATURE *

Clear
DATE *

Month Day Year
Date
I DECLARE THAT THE CLIENT VERBALLY CONFIRMED THE ACCURACY OF THE CONTENT OF THIS APPLICATION.
STAFF SIGNATURE

Clear
Date

Month Day Year
Date
Should be Empty:

RAPID RE-EMPLOYMENT APPLICATION

COVID STATUS

RELEASE OF INFO AUTHORIZATION

EMPLOYMENT CONFIRMATION