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Why does the applicant want to participate in the Dislocated Worker programs?
Employment Status at Enrollment
Ethnicity (check all that apply)
American Indian or Alaskan NativeAsian or Pacific IslanderBlack or African AmericanOther (include Multi-Racial Race)WhiteHispanic or Latino
Highest Level of Education Completed
High School Graduate or EquivalentSome College, or Technical or VocationalGED CertificateAssociate’s DegreeBachelor’s DegreeGraduate DegreeOther
Does applicant have the following accounts?
Dislocated/Displaced WorkerTransportationHomelessIndividual with Criminal RecordDisability (type of disability)Other
Applicant’s source of transportation:
Do you have any physical disabilities? If yes, please list:
Do you have any mental health concerns? If so, please list:
Do You Collect Any of The Following
Have you served in any of the following branches
NoneAir ForceArmyCoast GuardMarine CorpsNational GuardNavyReserves
Operation Iraqi FreedomOperation Enduring Freedom Other
Type of Discharge (if applicable)
AdministrativeHonorableMedicalOther than Honorable
Level of Clearance
Are you a Military Family Member?
Are you a Blue Star or Gold Star family member?
What is your Primary Relationship to Veteran?
DependentSpouseOtherNone I hereby certify that the information on this form is true and accurate to the best of my knowledge and belief. I understand that if I intentionally provide inaccurate information, I may be terminated from the Dislocated Worker Grant program and may be subject to legal penalties.
A part of your responsibility, as a participant in our program, is to work with your Career Navigator to explore your individual goals to obtain long-term employment. This document will assist you in outlining a specific plan that will allow you to identify strengths and barriers, professional development opportunities, and resources. All information will be kept confidential.
Are you currently employed?
What is your reason for participating in the program?
Find employmentFind a better job/careerFurther my education with career credentialingObtain financial assistance
What concerns will hinder you from maintaining your commitment to the program?
ChildcareEducationSpecial AccommodationsTransportationLegal IssuesJob ReadinessComputer SkillsOther
Please describe your concerns/immediate needs so that we may assist you.
What degrees and/or certifications do you possess? Please include your graduation year.
Please detail your employment goals.
Areas of Interest
AutomationBookkeepingCaring for adultsCaring for childrenCaring for animalsCashierClericalCoachingComputersCreative Arts CulinaryCustomer ServiceDrivingExercisingFashion/DesigningFood serviceGardeningHealth careHospitalityLeadershipMaintenanceManufacturingMechanicsMusicProblem solvingReadingReceptionistSalesSecretarialSewingSportsSupervisingTeachingTechnologyWelding
I hereby grant Palmetto Goodwill the right and permission to use “Tangible and Intangible Items” for any lawful, non-commercial purpose and in any and all media without payment or any other consideration.
In addition, I waive any right to inspect or approve the finished product wherein my likeness appears.
I hereby acknowledge that Palmetto Goodwill may grant the same permissions as set forth in this Consent and Release Form to Goodwill Industries International, Inc. (“GII”) under the same terms and conditions.
This Consent and Release Form shall remain in effect for a period of five years, unless revoked. I understand that I may revoke this consent by submitting a written request. I understand that, if I revoke this consent, my revocation will not have any effect on actions already taken by Palmetto Goodwill in reliance on my consent.
I have voluntarily enrolled as a participant with Palmetto Goodwill and by signing below, I certify that I have read and understand this program disclaimer. I have been given the opportunity to have my questions answered, and I have been informed that Palmetto Goodwill must give me a copy of this document once it is signed.
American Indian/Alaska NativeAsian/Native Hawaiian /Other Pacific IslanderBlack or African AmericanCaucasian Or White Other Race Or Origin
Is Primary Language Spanish?
Veteran/Person With Military History?
Are You Are Veteran With A Disability?
If Yes, Is It A Service Connected Disability?
Are You A Member Of A Military Family?
Are You A Caregiver For A Veteran?
Post 9/11 Veteran?
Education (Highest Grade Completed)
None1-4th Grade5-8th Grade9-12th GradeGEDHigh School DiplomaAssociates DegreeBachelors DegreeGraduate DegreePostsecondary Credential
Do You Identifiy With?
History Of Substance AbuseUnemployedDislocated WorkerIncumbent Worker Underemployed/Working PoorCriminal BackgroundImmigrant RefugeeLGBTQNo TransportationHomelessLack Of Child Care Services
Are You Currently Enrolled In?
High SchoolPostsecondary Non-Degree AwardGraduate DegreeGED/HS EquivalencyAssociate Degree
No DisabilitiesBlindness Or Other Visual ImpairmentLearning Disability Other Than AutismDeafness Or Hard Of HearingDevelopmental DisabilityPsychiatric DisabilityNeurological DisabilityEmotional DisabilityAutismOther Disabling ConditionOther Physical Disability
Walk In/Self ReferralEmployersState Agency For The BlindAdult Corrections Or Justice SystemJuvenile Justice SystemPostsecondary School/Community CollegesDept Of Defense Or Military Sevice AgencyVet Affairs Or Services AgenciesHomeless ShelterSNAP AdministrationTANF AdministrationWIOASSAState Voc Rehab AgencyElementary/Middle/High SchoolsOther Public Health, Human Or Social Service, Faith Based OrgMental Health Agency
Do you have any additional current certifications? If yes, please list all:
Have you completed any of the following trainings (check all that apply)?
Work ReadinessWork KeysComputer ClassesFinancial LiteracyOther
Are you receiving any of the following benefits or income supports (please check all that apply):
Child Care SubsidyEarned Income Tax CreditFree or Reduced LunchHead StartLIHEAP (utility bill assistance)MedicaidRental Housing Assistance/subsidySNAP (food assistance)TANF (cash assistance)UnemploymentWICSSI or SSDI
How would you rate your credit score?
1 = Very bad2 = Bad3 = About Average4 = Good5 = Very Good6 = Don’t know
Select the statement that best reflects your current situation when it comes to affordable medical care or adequate health insurance:
1 = No medical coverage with immediate need.2 = No medical coverage and great difficulty accessing medical care when needed. Some household members may be in poor health.3 = Some members (e.g. children) have medical coverage.4 = All members can get medical care when needed, but may strain budget.5 = All members are covered by affordable, adequate health insurance.
Select the statements that best reflects your current situation:
1 = I will be able to achieve most of the goals that I have set for myself.2 = When facing difficult tasks, I am certain that I will accomplish them.3 = In general, I think I can obtain outcomes that are important to me.4 = I believe I can succeed at most any endeavor to which I set my mind.5 = I will be able to successfully overcome many challenges.6 = I am confident that I can perform effectively on many different tasks.7 = Compared to other people, I can do most tasks very well.8 = Even when things are tough, I can perform quite well.
1 = New ideas and projects sometimes distract me from previous ones.2 = Delays and obstacles don’t discourage me.3 = I have been obsessed with a certain idea or project for a short time but later lost interest.4 = I am a hard worker.5 =I often set a goal but later choose to follow a different one6 = I have difficulty keeping my focus on projects that take more than a few months to complete.7 = I finish whatever I begin.8 = I am hard working and careful.
Select the statement that best reflects your current situation about physical & mental health:
1 = My immediate family or I have physical, mental, or substance use concerns that prevent my employment or daily life activities.2 = My immediate family or I have physical, mental, or substance use concerns that often interfere with my employment or daily life activities.3 = My immediate family or I have physical, mental, or substance use concerns that sometimes affect my employment or daily life activities.4 = My immediate family or I have no physical, mental, or substance use concerns that affect my employment or daily life activities.5 = My immediate family and I are healthy and participate in preventive health measures (examples include annual chek-ups, screenings, and vaccinations)
Select the statement that best reflects your current situation about food security:
1 = No food or means to prepare it. Rely to a significant degree on other sources of free or low-cost food.2 = Household is on food stamps.3 = Can meet basic food needs, but requires occasional assistance.4 = Can meet basic food needs without assistance.5 = Can choose to purchase the food that the household desires.
Please select the statement that best reflects your current situation about housing:
Homeless or threatened with eviction.In transitional, temporary or substandard housing; and/or current rent/mortgage payment is unaffordable (over 30 percent of income).In stable housing that is safe but only marginally adequate.Household is in safe, adequate subsidized housing.Household is safe, adequate, unsubsidized housing.
Please select the statement that best reflects your current situation about transportation:
1 = No access to transportation (public or private), may have car that is inoperable.2 = Transportation is available, but unreliable, unpredictable, unaffordable; may have car but no insurance, license, etc.3 = Transportation is available and reliable, but limited and/or inconvenient; drivers are licensed and minimally insured.4 = Transportation is generally accessible to meet basic travel needs.5 = Transportation is readily available and affordable; car is adequately insured.
Select the statement that best reflects your current situation about family care (includes child care, senior care and care for people with disabilities):
1 = Needs dependent care, but none is available or accessible and/or dependent is not eligible.2 = Dependent care is unreliable or unaffordable, inadequate supervision is a problem for what care is available.3 = Affordable subsidized dependent care is available, but limited.4 = Reliable, affordable dependent care is available, no need for subsidies.5 = Able to select quality dependent care of choice
Select the statement that best reflects your current situation about clothing:
No clothing or seriously inadequate clothing. (For example, no coat for winter months, shoes with holes in them or soles lacking, not sufficient clothes to assure clean clothes on a daily basis.) Unaware of where to access assistance. Very limited knowledge of resources for low-cost or free options to obtain clothing.Occasionally relies on community clothing banks. Has limited knowledge about community resources and/or financial resources to obtain clothing.Usually has the financial resource to purchase appropriate clothing. Aware of what is appropriate for work environment.Always has a financial resource to purchase appropriate clothing of choice. Aware of what is appropriate for work environment.
Palmetto Goodwill of SC is requesting additional information from some program participants for use in a pilot project for Goodwill Industries International. This data will be collected and shared, without use of names, for research and analysis. With the understanding that this information will be maintained in a password-protected database accessible only by authorized users, I authorize Goodwill to disclose necessary information, and hold Goodwill free from liability for the exchange of this information.
Administrative Headquarters 2150 Eagle Drive, Bldg 100 North Charleston, SC 29406 Phone: (843) 566-0072 Fax: (843) 566-0062
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