Are you a U.S. citizen and/or legally authorized to work in the U.S.A.? (required) Yes No

Are you a current resident of the State of Florida (required) Yes No

First Name (required)

Middle Name

Last Name (required)

Email (required)

Christian Help Account Password (Future Login) (required)

Cell Phone (required)

Street Address (required)

Apt #/Unit #, if applicable

City (required)

State (required)

Zip (required)

County (required) Seminole Orange Volusia Osceola Lake Polk

Who referred you to Christian HELP? (required) CFEC Website Church Client of Christian HELP Employee of Christian HELP Family Member Friend Hope Helps Internet Jail Program Job Fair Volunteer of Christian HELP Other

Please rate your level of English (required) Excellent Good Fair Poor

Employment Status (required) Unemployed Employed Underemployed Retired Other

Do you have any crime convictions? (required) None Misdemeanor Felony

Your current/last job title held? (required)

Dates of last employment? (required)

Wages of last employment (per hour)?

Wages of last employment (per month)?

Wages of last employment (per annum)?

Current Household Income (per year) (required) Under $20K $20K - $35K $35K - $50K $75K - $100K Over $100K

Do you have access to reliable transportation to and from work? (required) Yes No

Highest Level of Education (required) Doctorate (PHD) Graduate (Masters) Undergraduate (Bachelors) Associates Degree Technical School Certification High School Diploma GED High School No Diploma No Schooling Completed

Is the employment you are looking for? (required) Full-time with benefits Full-time Part-time Seasonal Other

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Employment Industries

1)    Healthcare & Social Assistance
a. Examples: Nurses, Physicians, therapists, social workers, counseling

2)    Technology & Professional Services
a. Examples: Software engineer, technician, data scientist, consultants, Administrative assistant

3)    Retail & Hospitality
a. Examples: Restaurants, hotels & travel employees, sales, chefs, event planning, Customer Service roles

4)    Education & Governmental Services
a. Examples: teacher, professors, government roles, law enforcement

5)    Manufacturing & Construction
a. Example: Warehouse laborers, contractors, electrician, engineers, construction, Shipping, Inventory Managers

6)    Finance & Business
a. Example: Accountants, insurance agents, auditor, financial, operations manager

7)    Other

  What type of employment are you currently searching for? (required) Healthcare & Social Assistance Technology & Professional Services Retail & Hospitality Education & Governmental Services Manufacturing & Construction Finance & Business Other

Gender (required) n/a Male Female Gender Questioning Gender-fluid Intersex Person Non-Binary person Transgender Man Transgender Woman Other Choose not to disclose

Current Living Situation (required) Rent Mortgage Owner Street Car Shelter Section 8 Temporary Friends or Family Permanent Friends or Family

Transportation Method (required) Vehicle Shared Vehicle Rely on others Bus Bike Walk Other

Birth Date (required)

Race (required) Black White Islander Asian

Hispanic (required) Yes No

Nationality (required)

Marital Status (required) Married Single Separated Divorced Widowed

Household Type (required) Adults and Children Under 18 Adults (over 18) Only Single Male Single Female

Number of adults in your household including yourself? (required)

How many children under 18 are in your household? (required)

U.S. Veteran? (required) Yes No

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When you request services through Christian HELP, we may connect you to partner community and faith organizations through The NewOrg software to work together in order to holistically address your needs and provide you with effective services. This release of information is written consent that upon your request, we may share your information with other service providers or agencies.

I understand that:
This agency will refuse to serve me simply because I do not want my information in their database system and may share with other service agencies at my request.
My written consent gives Christian HELP and NewOrg Management System software the permission to share limited personal information in their database system, which is a secure, encrypted web-based system. My information can only be shared with other The NewOrg software Partner Agencies within the secure system.
All organizations using the The NewOrg Management System software database are required to have security procedures in place regarding the protection and sharing of all client data. I have been assured that The NewOrg software has an interagency agreement regarding shared data.
This authorizes select information about me to be used to conduct research reports on the various types of resources, characteristics of those utilizing services, effectiveness of the services and patterns over time. I will not be personally identified by name, social security number or other unique characteristics in the research reports.

Image or Video Release

I authorize Christian HELP to use elements of my story, my photographs or video for media print and online advertising. I understand that my name will not be used in my story without my further permission, nor will I be compensated for my photographs or videos.

  Release of Information/Consent/Image+Video Release (required) I agree

Release of Information/Consent/Image+Video Release Date (required)