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Empowerme

2. emPOWERme
   A new Portland Housing Authority Resident Services Program.
   
   Thank you for your interest in the emPOWERme Program. Please complete the following so that a program coordinator will be able to contact you with information you are interested in.
4. First Name*
5. Last Name*
7. Preferred Language
8. Do you require an interpreter?
   -- Select One --YesNo
10. Address*
12. City
13. State
14. Zip Code*
16. Phone Number
17. Home or Cell?

    1. Home Phone

    1. Cell Phone
19. Email Address
20. How would you like to be contacted?*
    -- Select One --PhoneEmailTextMail
24. Interests*

    Please select all that interest you.

    1. Financial Coaching
    2. Increase Income
    3. Job Training
    4. Education

    1. Job Search/Employment
    2. Family Stability
    3. Homeownership

    1. Food Security
    2. Childcare
    3. Transportation
28. Highest Level of Education Completed:
    -- Select One --High School DiplomaHiSetGEDSome CollegeAssociate'sBachelor'sMaster'sTrade School Certificate ProgramOn the job training
29. Are you currently enrolled?
    -- Select One --YesNo
31. Current Employment Status
    -- Select One --Full-Time (30 hours/week or more)Part-Time (Less than 30 hours/week)FurloughedTemporaryLaid-OffUnemployed
32. If currently employed, what was your start date?
36. Assistance Receiving:

    Please check off all the boxes for assistance you are CURRENTLY receiving.

    1. TANF
    2. WIC
    3. EITC (Earned Income Tax Credit)
    4. General Assistance

    1. MaineCare/Medicare
    2. SNAP (Food Stamps)
    3. Childcare

    1. Social Security Benefits
    2. Unemployment
    3. Other
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field