Form

First name*

Last name*

Age*

Gender Identification*

Email*

Phone number*

State*

Postal code*

Are you Affiliated with the U.S. Military?*

What is the highest level of education you have completed?*

Did you receive any of the following public assistance benefits? SNAP, TANF, SSI, Medicaid, Housing Choice, Voucher Program (Section 8), WIC, and/or EITC*

Yes

I don't know

Total earnings ($) from employment based on your previous year tax return.*

Please share your job experience over the past 12 months (industry, job, title, etc.). If you were not employed over the past 12 months, please write "Unemployed."*

Please provide the following: Number of children aged 0-3 in household*

Please provide the following: Number of children aged 4-17 in household.*

Please provide the following: Number of adults in the household. *

Are you the Head of Household?*

Yes

By participating in this program, you consent to having your data shared among the UpSkill Miami partners, (The CDL School and United Way Miami) for program coordination purposes. Staff follow strict rules to protect your data. Your name and any other personally identifiable data will never be presented in any published reports. Do you consent to the terms above?*

Yes