Jefferson-Franklin WIOA Intake Form

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Workforce Innovation and Opportunity Act (WIOA) funds may be available to eligible individuals residing in Jefferson or Franklin Counties (Missouri) or if the eligible individual is planning on attending/working at a training provider/employer located in either county.

Please complete this intake form to be screened for possible grant tuition assistance:

If eligible, you may be enrolled in one or more of these services based on need and funding availability:

• Adult Education and Literacy to complete high school equivalency diploma
• Work Experience (pays at least the most current minimum wage rate)
• Career Assessment and Career Development assistance
• Financial Literacy workshops
• Assistance with college tuition and fees
• On-the-job training opportunities

Full Name (First, Last) *

Email *

Which County do you live in? *

Jefferson

Franklin

Other:

Phone number *

What is your age? *

(Males over 18 only) Are you registered with the Selective Service or are you willing to register? (This is a requirement for this program) *

YES

N/A - I am Female

Do any of the following apply to you? (check all that apply) *

Apart of household receiving SNAP or TANF

Homeless

Have learning, mental, or physical disabilities

Received unemployment insurance benefits within the past 5 years

Impacted by a recent layoff or closure

Veteran of the US Military

Spouse of an Armed Service Member

Age 24 years of age or younger AND pregnant/parenting

Foster child or aged out of foster system

Involved in the juvenile/adult criminal justice system

Need to obtain your high school equivalency-HiSET

None of the above apply

Required

I am interested in more information about: (check all that apply) *

Tuition Assistance

Obtaining my HiSet/GED

Work Experience (for those with limited prior work experience)

On-the-Job Training opportunities

Employment assistance (Resume and Interview help and/or help finding job openings)

Financial Literacy Workshops

Other:

Required

How did you hear about the program?

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