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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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Presidents Day: Monday, February 16.

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