Additional Information - Appalachian Region - Code:You

Code:You Additional Enrollment Information for Appalachian Residents

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Thank you for completing the pre-work and enrolling in Code:You! We just have a few more questions to get you enrolled – this form should only take a couple minutes to complete. These questions are specifically required by a grant that makes Code:You available free to residents of the Eastern and Appalachian regions of Kentucky.

If you experience any difficulty in completing this form, please contact a program coordinator. If you’re not sure who to contact, please email info@code-you.org

Confirm Your Contact Information

Please use the same name and email address you used when you signed up for the program. It should be the same one we’ve been communicating with you through for the pre-work. Using the same name and email will ensure your record is updated properly in our system. If a match is not found, this form will show an error. Please try again.

If you are having any issues submitting this form, or if you prefer to give your SSN over phone, please contact the Community Coordinator that you have been working with or email info@code-you.org.

First Name

Last Name

Phone Number

Availability

Please select which night of the week you would like to attend class meetups. Continue to check your email regularly for more information about the upcoming session. **Note: You must attend on the night you select for the whole session. Additionally, class schedules may need to change based on demand and instructor availability – we will contact you if your chosen date becomes unavailable.

Work Eligibility

Code:You is funded through various grants, including federal and state funds that require us to collect and report certain information on our participants, including Social Security Number. Your SSN will be stored securely and will only be used for reporting purposes. All data is anonymized so that your name and other identifying information is not sent alongside your SSN.

Social Security Number

Please enter numerical values only (No Dashes [-])

While the collection of this information is important for the Code:You program, if you prefer to not provide this information at this time, please check the box below.

I do not wish to disclose this information at this time.

Code of Conduct

Participants must adhere to the Program Code of Conduct at all times during the program. Please review the Code of Conduct document in the link below:

CODE OF CONDUCT

I have read and understand the Code of Conduct.

I agree to abide by the rules described in the Code of Conduct and understand that I may be removed as a participant if I violate any of these rules.

Please type your full name below to mark that you have provided accurate information on the form above, read and understand the Program Code of Conduct, and are agreeing to abide by the Program Code of Conduct.

Additional Program Information

Were you unemployed for 27 or more weeks immediately before beginning this program?

Do you have a disability?

If Yes, please indicate your primary disability.

Are you currently receiving TANF Benefits/Services?

At the time of program entry, were you (or are you) within two (2) years of exhausting lifetime TANF Benefits?

Are you able to comfortably Read and Write in English?

Do you feel that you experience any cultural barriers which may make it more difficult for you to be employed?

Are you a single parent?

Before starting this program, have you been a home maker, stay-at-home parent, or unpaid caregiver to a family member in your home, AND have you experienced difficulty in obtaining or upgrading your employment?

Were you supported by the income of a family member, but are no longer supported by that income?

Are you the current spouse of, or have you been married to, a member of the Armed Forces on Active Duty, AND did you have to quit your job or lost income due to the deployment, permanent change of station, or death/disability of that Service Member?

Before beginning this program, were you or the primary earner in your household working in the Agricultural or Fish Farming Industries in a role that was seasonal or involved a lot of travel?

For more information or to contact us, email info@code-you.org or go to: https://code-you.org/contact