Pre-Application Screening Form
RequiredRequired Question(s)
Progress: 
 
Required 1.

Name (First and Last)
 

50 characters left.
Required 2.

Address (Street, City, State, Zip)
 

50 characters left.
Required 3.

What Parish do you live in?
 

50 characters left.
Required 4.

Phone Number (with area code)
 

50 characters left.
Required 5.

Email
 

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Required 6.

Date of Birth (Month/Date/Year)
 

50 characters left.
Required 7.

Age
 

50 characters left.
Required 8.

Gender
Male
Female
Required 9.
Are you of Hispanic or Latino Ethnicity
Yes
No
Required 10.

Race 
White
African American/Black
American Indian/Alaskan Native
Asian
Hawaiian/Other Pacific Islander
Other  
11.

Do you have a disability?
Yes
No
Required 12.

Are you a U.S. Citizen?
Yes
No
13.

If you are NOT a U.S. Citizen, are you a registered alien/refugee?
Yes
No
Required 14.
Are you registered with Selective Service (Males 18 or Older)?
Yes
No
Required 15.

Are you a Veteran?
Yes
No
Required 16.

Are you Separating or retiring from the military?
Separating
Retiring
No
Required 17.

Are you a military Spouse?
Yes
No
18.

If you are a Veteran please fill out your entry and discharge dates:
 

50 characters left.
19.

If you are a Veteran what type of discharge did you receive?
Honorable
Less than honorable
Dishonorable
Other  
Required 20.

Highest grade of education completed:
Less than High School
High School Graduate
Received GED
Technical College
Some College
2 yr. College Graduate
4 yr. College Graduate
Post Graduate
Required 21.

Current School Status:
Not attending any school
Attending High School
Attending GED or HS equivalency classes
Attending college
Attending technical college
Attending post graduate school
Required 22.

Name of School(s) graduated from and years:
 

50 characters left.
Required 23.

Are you a drop-out?
Yes
No
24.

If you are a drop-out, what grade?
 

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25.

If you are a drop-out, name of school dropped from:
 

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26.

Do you have a GED/HiSET?
Yes
No
27.

If you do have a GED/HiSET, name of school and year:
 

50 characters left.
Required 28.

Are you planning to attend school?
Yes
No
Required 29.

Are you perusing any of the following?
GED
Diploma/Certificate
Associate's Degree
Bachelor's Degree
No
30.

If you are planning to attend school, name of school planning to attend:
 

50 characters left.
31.

If you are planning to attend school, what course/major?
 

50 characters left.
32.

If you are planning to attend school what is your planned start date?
 

50 characters left.
Required 33.

Do you have a valid driver's license?
Yes
No
Required 34.

Are you a single parent?
Yes
No
Required 35.

Are you pregnant?
Yes
No
Required 36.

Have you recently divorced?
Yes
No
37.

If you HAVE recently divorced, when?
 

50 characters left.
Required 38.
Have you recently separated from your spouse?
Yes
No
39.

If you HAVE recently separated from your spouse, when?
 

50 characters left.
Required 40.
In order to determine need for additional services are you a victim of spousal abuse?
Yes
No
Required 41.
Are you living in a state recognized shelter?
Yes
No
42.

If you ARE living in a state recognized shelter, how long?
 

50 characters left.
Required 43.
Do you have transportation to get to school or work?
Yes
No
Required 44.
Do you rely on public transportation to transport you?
Yes
No
Required 45.
Do you live in public housing?
Yes
No
Required 46.
Are you a runaway?
Yes
No
Required 47.
Are you homeless?
Yes
No
Required 48.
Are you a foster child?
Yes
No
Required 49.
Did you fail LEAP/GEE?
Yes
No
Required 50.
Do you have substance abuse problems?
Yes
No