EmailMe Form - County Futures Application

Name *

First name, middle initial, last name

Email *

Phone *

Birth Date *

MM / DD / YYYY

Address *

Franklin County Residents Only

Address Line 2

City *

Zip Code *

Emergency Contact Name and Phone Number *

Are you a citizen of the United States? *

If you are a non-citizen but eligible to work, please provide your number

Gender *

Race *

Do you have a disability? *

How did you hear about the program? *

What is your education status? *

What is your criminal history? *

If you are on probation, what is the name of your Probation or Parole Officer?

Do you have any outstanding warrants or pending court cases against you? *

If yes, which county is your pending court case in?

Can you pass a drug test? *

Acknowledgement: By signing this document, you certify the information you have provided is accurate to the best of your knowledge. *

I agree to provide CCOHF with the information regarding my education and employment at any time. I authorize any party such as federal, state, county agencies and/or employer and training providers to release information during and up to 12 months from enrolling. *

I authorize CCOHF to release and acquire information to facilitate my participation in CCOHF programs. The purpose of exchanging information is to maximize community resources reduce duplication of information and services, and to verify performance of services. Information may be released or acquired from the following: education, workforce alliance agencies, human services organizations, and employers. *

Photo/Video Authorization: I grant CCOHF Staff and representatives the right to photograph me. I authorize CCOHF and its assignees and transferees to copyright, use, and publish photos in print and/or electronically. I understand that the photographs become the property of CCOHF and I release CCOHF from any liability associated with the display of the images published. I agree that CCOHF may use such photographs of me with or without my name and for any lawful purpose. *

Police report authorization: I authorize CCOHF to obtain a copy of my current police report through the Franklin County Sheriff Department and Columbus Bureau of Police. The information obtained will be kept confidential and used only for verification of potential barriers to employment. The information will not be released to any unauthorized. *

By signing this authorization, I give CCOHF and its programs permission to release or acquire any program specific information. *

Signature

Clear