Interest Form
Fill the form below accurately indicating your potentials and suitability for the training program you're interested in.
Name:
*
First Name
Last Name
Home City:
*
Home Zip code:
*
Personal Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Service Planning Area:
Please Select
Who Referred you to this W.E.R.C Training Program?
*
Current or Former W.E.R.C. Program Participants (HCAI, HR, or Other)
Service Provider Agency (Homeboy Industries, Sidewalk Project, LACADA, etc.)
Other
Name of the service provider agency:
*
Do you have a valid California Class C Drivers License?
*
Yes
No
Do you have a valid High School Diploma or equivalent (GED or Vocational Certificate?
*
Yes
No
Please select all that is applicable to you:
*
Justice System Involved
Homeless / Housing Insecure
History of Sex Work
History of Substance Use Disorder
What is the best time in a day to reach out to you?
*
Please, check all time of the days you are available for the follow up call:
*
Mornings (9am-12pm)
Afternoon (1pm - 4pm)
Evenings (4pm - 5pm)
Please check all dates/times you are available to attend an Information Session:
*
Mornings (10am - 12pm)
Afternoon (1pm - 3pm)
Staff Follow up
Staff Name
First Name
Last Name
First Follow Up Date:
-
Month
-
Day
Year
Date
Left Voicemail after call ?
Yes
No, unable to (VM full, not set up, etc.)
N/A
Notes
Second Follow up Date:
-
Month
-
Day
Year
Date
Left Voicemail after call ?
Yes
No, unable to (VM full, not set up, etc.)
N/A
Notes
Invited to Info Session?
Yes
Does not meet program eligibility or job requirements
No, no longer interested
Unable to attend
Reach out after 6 months
Date of Info Session invited for:
/
Month
/
Day
Year
Date
Did they attended ?
Yes
No
How did you hear about WERC harm reduction workforce development program ?
*
Please Select
Word of Mouth
Referred by WERC Alumni
Referred agency/organization
Name of the referral agency/organization
*
Please, select the agency type that you are part of ?
*
Please Select
Community-based (e.g. Non-profits)
Research-based (e.g. Universities, Schools)
Healthcare-based (e.g. Hospitals, Clinics)
Government-based (e.g. State, County Department)
Signature
*
Date of Signature:
*
/
Month
/
Day
Year
Date
Submit Your Interest Form
Should be Empty: