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Home
Family Self-Sufficiency Program Form
Family Self-Sufficiency Program Form
Participant Code with the AHA (t-code)
This number can be found on most correspondence with the AHA.
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Main Phone
(Required)
How many adults in your household?
How many minors in your household?
Total in Household
Do you have internet access?
Yes
No
Does your household include a member with a disability?
Yes
No
Do you currently receive financial housing assistance?
(Required)
Yes
No
Answer “Yes” if you have a Housing Choice Voucher (HCV) or a Project-Based Voucher (PBV), but not project-based rental assistance (PBRA).
What type(s) of income/benefits does your household receive? Check all that apply.*
Self-employment/ own my own business
Employment
Cal-Works
General Assistance
SSI/SSA (Social Security)
Child/Family Support
Food Stamps/SNAP
Unemployment
Medicaid/MediCal
Other
Other (Financial Assistance)
What is the best way to reach you?
Phone
E-mail
Regular Mail
Highest Education Completed
Did not complete High School
Graduated High School/Received GED
Completed Trade School or other training program
Some College
Graduated College
Advanced College Degree
Do you currently attend any education or training programs?
Yes
No
Is Child Care needed for you to work or pursue educational program?
Yes
No
What kind of experiences/services do you need to become self-sufficient? (Check all that apply)
GED/High School Diploma
Apprenticeship/Trades
Financial Assistance
Hands-on Job Training
English as Second Language
Certificate or Associates’ Degree
Career Exploration
Money Management/Credit Repair
Job Search/Interview skills
Bachelor’s or Master’s Degree
Computer Training
Transportation
Employment
Parenting Education
Other
Other (Income/benefits)
How did you hear about the Family Self-Sufficiency (FSS) Program?
Why do you want to participate in the FSS program?
The FSS Program requires monthly contact with FSS Coordinator and participation in FSS events and workshops. Would this pose a problem for you?
Yes
No
If you live in the City of Alameda, are you interested in moving to another town?
Do not live in City of Alameda.
Yes
No
Are you interested in homeownership?
Yes
No
Would you like to be added to our e-mail?
Yes
No
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