Application for Rising Above
Please fill-in and submit the form below.

First Name 
Initial 
Last Name 
Address 
City 
State 
Zip Code 
Phone 
Alternate Phone 
e-mail 
Social Security #    (optional)
Date of Birth 
Gender 
Race 
Marital Status 
Number of minor children 
Eligibility Information - DO NOT LEAVE ANY SECTION BLANK
- ENTER N/A FOR NON-APPLICABLE
Highest level of education 

GED
High School Diploma
Tech/AA/2 yr
College
Post Secondary
None of the above
Do you have any certified skills? 
Have you ever been convicted of a felony?  No    Yes (see below)
If yes, please list 
Are you on parole?  Yes   No
Are you on probation?  Yes   No
Can you pass a drug test?  Yes   No
Do you have a drivers license?  Yes   No
Do you have auto insurance?  Yes   No
List 3 types of jobs you are interested in: 
Job type 1 
Job type 2 
Job type 3 
Are you interested in training 
opportunities? 		 Yes   No
Please list 
Do you have any active warrants 
for your arrest? 		 Yes No
Please state nature of warrant(s) 
Do you have legal custody 
of your minor childern? 		 Yes No
Do you have to pay child support?  Yes No
Do you live in the same household 
as your minor children? 		 Yes No
Does your children receive 
public assistance? 		 Yes No
Names of Minor Children Name of legal Guardian of children 
What self-sufficiency services 
do you need assistance with?		 Housing
Employment
Training
GED
Day Care
Transportation
Clothing
Medical
I here by authorize the Rising Above representatives to supply any or all parts of the information contained in this application to the Cuyahoga County Service Agencies and or their representatives in an effort to determine eligibility for employment and training services through Rising Above Initiative as so verified by my acceptance below.
  

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