Intake

Boozhoo! / Aaniin!

Miigwech bi-izhaayan omaa Ombishkaaiwewug Transitional Housing by Northwest Indian Community Development Center.
Name

First NameLast Name
Anishinaabe Name
Clan
Tribal Affiliation
Date of Birth

MonthDayYear
Date
Age
Gender Identity
SSN
Are you currently incarcerated?*

YesNoSupervised ParoleUnsupervised ParolePending Release
Case Number: *
County of Jurisdiction: *
Case Manager's Name *

First NameLast Name
Parole Officer's Name*

First NameLast Name
Are you currently experiencing housing insecurity?

YesNoUpon release from jail or prison
Are you currently pregnant?

YesNo
Current Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email
example@example.com
Race - Select all that apply

Native American / Alaskan NativeAsianAfrican AmericanHawaiian Native / Pacific IslanderHispanic / LatinoWhite
Are you a US citizen?

YesNo
If you are not enrolled into a tribe, are you eligible for enrollment?

YesNo
Are you a descendant?

YesNo
Are you a veteran?

YesNo
Emergency Contact

Full NameRelationship
Emergency Contact Phone Number
Please enter a valid phone number.
Do you require special care or assistance or special accommodations? If so, please explain.
Cultural Needs

Traditional events / gatheringsOjiwemowin opprotunitiesTraditional / cultural teachingsSearching for my clanCounseling from Elder / HealerTraditional help / advice on intense mattersBeading InstructionRicingSugar Bushing
Education / Employment

Receiving assistance applying for collegeReceiving assistance with training opportunitiesAssistance with financial aid / FAFSAAssistance navigating college / career explorationAssistance with resume developmentConducting practice interviewLearning new skills for workplaceInterest in the community health worker certificationInterest in Certified Nursing Assistant program (CNA)Interest in Occupational Safety and Health Admin. (OSHA)Interest in Miiqwech Aki (Deconstruction program)Learning new technology skills
Needs of family and self

Mental health referralsAdult Basic Education ProgramsJob application supportAssistance in obtaining photo IDAssistance in obtaining Tribal IDAssistance in obtaining Social Security CardInformation / support for navigating family reunificationMeal preparationHousing assistanceSecuring childcareTax preparationInformation about support groups (AA, NA, Womens, Mens)Assistance with transportation (gas card / bus tokens)Assistance with NWICDC drop-in services (phone, fax, internet)Artistic opportunitiesLearning new art techniquesVolunteering opportunities at NWICDC
Equal Opportunity is the Law

It is against the law for this recipient of Federal financial assistance to discriminate against the following basis:

Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation, or belief. We consider applicants without regard to race, color, creed, religion, national origin, age, sex, political affiliation or belief, marital status, disability, sexual orientation, or status without regard to public assistance. It is our policy to abide by all federal, state, and local laws concerning discrimination; and against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA) on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title financially assisted program or activity. The recipient must not discriminate in any of the following areas:
- Deciding who will be admitted, or have access to any WIA Title financially assisted program or activity
- Providing opportunities in or treating any person with regard to such a program or activity or
- Making employment decisions in the administration of, or in connection with such a program or activity
What to do if you believe you have experienced discrimination?

If you think that you have been subjected to discrimination under WIA title I financially assisted program or activity you may file a complaint in writing 180 days from the date of the alleged violation with either:

Martin Jennings, Director

Northwest Indian Community Development Center Civil Rights Center (CRC)

1819 Bemidji Ave, U.S. Department of Labor

Bemidji, MN, 56601 200 Constitution Avenue NW

Phone 218-759-2022 Room N-4123

If you file a complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above).

If the recipient does not give you a Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that notice before filing a complaint with the CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the date on which you received your complaint with the recipient).

If the recipient does not give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with the CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.

The above notice to the public applied to the federal programs covered under the Workforce Investment Act (WIA). Complaints concerning the services provided by non-WIA programs may be processed differently.
Tenessen Warning Notice

Please read the Tenessen Warning Notice below and the equal opportunity information. Please sign the bottom.

The data we are asking you to provide about yourself is considered private data by Minnesota Statute 13.47 subdivision 2. In order to collect and use this data we must tell you why we need the data, how we intend to use it and any consequences you may experience if you supply the information or not.

Why we need the data
- Your Social Security Number is requested to identify you as a unique individual and to find out wage data to help us determine how well our services helped you.
- Personal characteristics: age, gender, ethnicity, race, disability, and economic status is collected to evaluate our performance and in some cases to determine if you’re eligible for special assistance.
- Veteran status is asked to determine if you are eligible for special services and to evaluate our service delivery.
- Work and education history is used to help you plan your employment and training.
How we intend to use the data and to whom we may share this information:

Work and education history may be shared with prospective employers. In addition to analyzing this data to improve our services, we may share information about you with other employment and training service providers in order to determine what services you may be eligible for and to coordinate services provided to you. Data may be shared with federal and state entities that provide funding for workforce center services. Additionally, other government entities with a legal right to this data may see your information.

Consequences to you if you choose to not provide this information.

You may refuse to supply any or all of this information, you are not legally required to provide any of this information to use workforce development services, and not supplying sufficient information may limit our ability to provide you the services you want.

For more information:

DEED Data Practices www.deed.state.mn

Minnesota Data Practices Act www.resivor.leg.state.mn.us/stats/13/

Minnesota Department of Administration Information Policy Analysis Division

Equal Opportunity is the Law

We consider applicants without regard to race, color, creed, religion, national origin, age, sex, political affiliation, belief, marital status, disability, sexual orientation, or status with regard to public assistance. It is our policy to abide by all federal, state, and local laws concerning discrimination.

Complaint and appeal policy:

If you feel that anyone in our office has treated you unfairly, you have the right to file a complaint. If you have been denied services, you have the right to appeal. If you wish to file a formal complaint or an appeal, please see a staff member for assistance.

I have been made aware of and understand this Tennessen Warning notice. (If you do not understand this statement, please ask that a staff member explain it to you.)

I agree that the information on this form may be shared among Minnesota Workforce Center agencies for the purpose of helping me find employment or training.

I was presented and have read the equal opportunity information on the Notice to the Public Equal Opportunity is the Law.

I also understand that I have the right to file a complaint of discrimination.
Write down an employment, education or personal goal.
What kind of job do you see yourself in?
Would you consider going to school?
What would you like to focus on?
What can we do to support you on your path?
How will you reach this employment, schooling or personal goal? List at least 3 action steps you'll take (please be specific)
Make your goal measurable. I will measure/track my goal by using:
Make your goal attainable. Who is going to help you with your goals?
List skills and resources you need in order to meet your employment, schooling or personal goals.
Goal for check in date 1 (1-3 months)
Goal for check in date 2 (3-6 months)
Goal for check in date 3 (6-9 months)
Member Signature

Clear
Should be Empty:

Boozhoo! / Aaniin!