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This program requires the active participation and communication of the enrolled participant for up to 12 months after the start date of employment. This means timely completion of requested documents, attendance at employment events, participation in financial education awareness activities, keeping a job log, regular email or phone contact with program staff, as well as keeping up-to-date personal contact information on file.
I will actively participate in program activities and will actively communicate with program staff
I understand failure to follow through on the requested program activities without communication with program staff and will result in dismissal from the program.
I understand that while information provided will be kept conﬁdential, it will be entered into the program management database. Additionally, that this information will not be shared with third parties without written consent.
I hereby knowingly and voluntarily consent to the disclosure and exchange at any records or information pertaining to my employment verification.
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 oil 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“) and Palmetto Warrior Connection 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 l 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 in the Operation GoodJobs Program and by signing below, I certify that I have read and understood this program disclaimer. l 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.
Your Individual Career and Financial Plan (ICFP) will help you plan your goals and work toward them with assistance from the Operation: GoodJobs Team. First, your plan will outline any obstacles you may be encountering in obtaining or maintaining employment. Second, your plan will outline your strengths, aptitudes, and abilities, and finally, your plan will include your overall goal(s) and the steps you plan to take to achieve them considering your strengths to manage the obstacles to obtaining or retaining employment.
All information provided in this document will be kept CONFIDENTIAL. We will disclose protected information only as required by federal law in instances involving possible victims of physical assault, neglect, financial exploitation, rape or sexual molestation, and domestic abuses of elders, spouses, partners, or children.
Are you currently unemployed?
If yes, for how long?
01 – 12 weeks13 - 26 weeksmore than 26 weeks
If no, how many hours per week do you work, and what is your rate of pay?
What is your primary reason(s) for participating in Operation: GoodJobs?
Find employment (full-time, part-time, temporary).Find a better job (career advancement).Further my education (GED, College courses, OtherBetter financial awareness.Help my family's future.
Why do you wish to enroll in Operation: Good Jobs?
What concerns do you feel hinder your ability to maintain a job or advance in your current position?
ChildcareTransportationEducationLegal IssuesFinancialSpecial AccommodationPublic Assistance
Childcare: Do you have children?
Do you need assistance in finding reliable childcare?
What is your primary mode of transportation?
Do you have a valid driver's license?
Do you have a valid CDL?
Do you need assistance obtaining a license?
Do you own a car?
Have you ever been convicted of a felony?
If yes, what years, and what were your conviction(s):
Do you have any outstanding warrants?
Are you currently on probation/parole?
Do you have documented disability that prevents you from working?
If yes, please explain:
Do you have any health issues that prevents you from working?
Are there any additional needs or accommodations that you require to go to work?
List degrees and/or certificates. Please include school and graduation year:
Are you interested in other training classes? If so, please describe.
Check the box by each statement that applies to you. Please be as truthful as possible.
I know exactly how much total debt I haveI calculate my net worth (total assets minus total debts) annuallyI have an emergency saving account with at least $600 in itI have a written budget or spending planI have written financial goals with a date and dollar amount (ex: $1,000 for new computer by Jan '16)I have enough money each month to pay my rent or mortgage payment and all other household billsI plan for expenses that only come up once or twice a yearI have adequate life insuranceI have homeowners or renters' insuranceI pay my credit cards in full each monthI know the interest rate on all my credit cardsl am saving for retirementI have a will and advance medical directivesI always pay my bills on time and do not have any late payments on my creditI have reviewed my credit report within the last yearI know my credit scoreI comparison shop for services and major purchases by checking at least three sourcesI have never used a payday or title loanI have a checking accountI keep organized financial records and can find important documents easily
Financial Fitness Level - Count up the number of checkmarks to get your score. If you scored 16-20, you are doing a great job and are above average in managing your finances. If you scored 11 - 15, you are doing a fair job of managing finances and have taken some steps in the right direction. If you scored 6 - 10, you are headed for financial difficulty. Now is the time to act and get back on track. If you scored 0 - 5, you need lots of help, but don't worry! It is never too late to take steps to improve your finances.
Crafting S.M.A.R.T. Goals are designed to help you identify if what you want to achieve is realistic and determine a deadline. When writing S.M.A.R.T. Goals use concise language but include relevant information. These are designed to help you succeed, so be positive when answering the questions.
Initial Goal (Write the goal you have in mind):
Specific (What do you want to accomplish? Who needs to be included? When do you want to do this? Why is this a goal?)
Measurable (How can you measure progress and know if you've successfully met your goal?):
Achievable (Do you have the skills required to achieve the goal? If not, can you obtain them? What is the motivation for this goal? Is the amount of effort required on par with what the goal will achieve?):
Relevant (Why am I setting this goal now? Is it aligned with overall objectives?):
Time-bound (What's the deadline and is it realistic?):
I participated in the development of this plan. I understand that this is my plan and the goals outlined in the plan are mine. I may at any time choose to make changes to my plan. I understand that the Operation: GoodJobs Staff will review my plan periodically. The staff may make recommendations for updates and modifications to my plan so that I may achieve my goals, but it is my responsibility to uphold the responsibilities outlined in my plan and to work with the Operation: GoodJobs Staff and my support system to attain success. I understand that this program is a minimum one-year agreement and I will maintain a working relationship throughout this time. My signature below indicates that I have received a copy of my plan and that I agree to work towards the goals that I have outlined.
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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