BSCC Grant Participant Sign in First Name Last Name(Required) Email Address(Required) Were you referred to this program?(Required) Yes No Referred meaning "mandated" or voluntary.Is this your first, second or third time enrolling into this program?(Required) First Second Third Which age group do you belong to?(Required) 18-30 Years 31-40 Years 41-50 Years 51-60 Years 61 Years or Older Which gender do you identify as?(Required) Female Male Non-binary/ 3rd Gender Prefer to Self-Define Prefer Not to State Other Unknown What is your race/ ethnicity?(Required) American Indian/ Alaskan Native Asian Indian Asian (Other) Black or African American Cambodian Chinese Decline to State Fillipinio Guamanian Hispanic, Latino, or Spanish Japanese Korean Laotian Middle Eastern/ North African Multi-ethnic origin, ethnicity, or race Native Hawaiian Native Hawaiian/ Pacific Islander (Other) Other identified ethnic origin, ethnicity, or race Samoan Unknown Vietnamese White Are you currently enrolled in an education program?(Required) Obtaining GED College/ University Vocational School Other school/ training Not currently enrolled If you are not currently enrolled in an education program, do any of the following apply to you?(Required) High School diploma or GED Did not graduate College graduate Currently enrolled in an education program What is your current employment status?(Required) Student - not looking for employment Student - looking for parttime employment student - looking for fulltime employment Employed - not looking for employment Employed parttime - looking for additional parttime employment Employed parttime - looking for fulltime employment Employed - looking for fulltime employment Employed fulltime - looking for additional/ other employment Not employed - looking for employment Other (not employed or a student, but not looking for employment due to disability, treatment, etc.) If you were recently incarcerated, how long has it been since your release from an institution?(Required) 0 days - 6 months ago 7 months - 12 months ago 13 - 24 months ago 3+ years Are you currently engaged in any of the following activities or receiving any of the following services? (Check all that apply)(Required) Access to basic needs Referrals to community-based support services Referrals to housing Referrals to mental health services Referrals to substance use services Referrals to Public Assistance Referrals to employment services Referrals to education services Referalls to any other services not listed here Leadership/ mentor training Individual/ group mentoring Life skills training Skill building activities Workshops Pro-Social activities/ recreational events Which site or chapter are you attending? The Grove Chapman House Sacramento Chapter Orange County Chapter
