ACCESS Miami - Enrollment Form

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Enrollment Form

In order to serve you better, please fill out this brief enrollment form.

Tell us about yourself

First Name

Last Name

SSN# (only the last 4 digits are required)

Income Tax Identification Number (ITIN - only the last 4 digits are required)

Gender.

Male

Female

Marital Status

Single	Married	Widowed
Other

Date of Birth

City

State

Zip

Home Phone

Cell Phone

In Which Program Are You Interested?

Education

Computer Literacy

Do you own a computer?

Yes No

Do you have Internet access?

Yes No

What type of computer skills do you have?

Tell us about your background

I am a U.S. Citizen

Yes No

I am a refugee or non-citizen

Yes No

Are you a U.S. Veteran?

Yes No

Have you ever been arrested or convicted of a crime?

Yes No

Work & Training

Are you currently employed?

Yes No

Are you looking for training opportunities?

Yes No

Are you looking for a new job?

Yes No

Languages

English

Speak

Read

Write

Spanish

Speak

Read

Write

Creole

Speak

Read

Write

In order to better serve you, please check off the items that apply:

I am currently receiving Cash Assistance, Food Stamps, SSI, or Medicaid

Yes No

I am currently enrolled in school or training

Yes No

I have the necessary transportation to maintain employment

Yes No

Please enter the security code shown

Authorization to use this form
By clicking "submit", I acknowledge that all the information I have provided is true and accurate. I understand that additional information may be required from me to assist in the search for potential employment and training programs. This information will be kept confidential and will be used in connection with City of Miami programs and services, and in connection with City of Miami partners that may be able to provide additional resources.