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HOWTO Eligibility Assessment

Please complete the following form so that HOWTO Coach can best assess your eligibility for the program. Your information and answers will be kept confidential and shared only among staff belonging to HOWTO Grant.
First and Last Name:*
E-mail:*
Phone Number
How did you hear about this program? If referred by DHS, please include your Family Coach/Case Manager name and contact information.*
What is your age?*
Address:*
Are you legally able to work in the US?*
Would a criminal background prevent you from working in healthcare career field?
Are you able to pass a drug test?
Are you currently working?*
Do you identify as low income?*
Do you identify as a veteran or an eligible spouse of a veteran?
Are you receiving any of the following public benefits?*
Other public benefits:
DHS Family Coach Name (TANF Case Worker):
HOWTO promotes diversity within the healthcare industry. Do you identify as the following? (Choose all that apply.)*
Are you interested in a particular healthcare occupation? If so, please tell us here.*
Have you ever worked in the healthcare field? If so, please tell us more.
Do you already have any education or training in the healthcare field? If so, please tell us more.
If there's anything else you want to share with us, please tell us here:
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