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Step 1 of 6

16%

*Required
Demographic Information
Applicant's First Name*
Applicant's Middle Name (Initial)*
Applicant's Last Name*
Applicant's Date of Birth (MM/DD/ YYYY)*
Phone Number (555-555-5555)*
Email Address*
Street Address and Apartment/Unit Number (If Applicable)*
City*
State*
Zip Code*
County (if known)
How did you hear about the Pathways Program for Single Moms? (If you were referred by someone, please list here)*
Please select the race/ ethnicity you identify with
**(You may choose multiple options. If you do not see your race/ ethnicity listed, or you require further specificity for accuracy, please write it in Question 10.)**
- American Indian/ Alaska Native
- Asian
- Black or African American
- Latinx
- Multiple Races (Specify Below)
- Native Hawaiian or Other Pacific Islander (Specify below)
- White (Non-Latinx)
- Will write answer below
If you did not see your race/ethnicity listed 9, or you require further specificity for accuracy, please write it in here.
What language(s) do you use most prominently? (If multiple, please list all)
Veteran Status*
- Veteran
- Service-Disabled Veteran
- Member of the Reserve
- Member of the National Guard
- No Military, Reserve or National Guard Service
- Decline to disclose veteran status
- Other
Do you identify as having a disability?*
- Yes
- No
- Not sure
Which best describes your current marital status?*
- Single
- Married
- Separated
- Divorced
- Widowed
Who lives in your household? (check all that apply)*
- My romantic partner/spouse
- My own children
- Other children who are related to me (or my partner) (e.g. nieces, nephews, cousins)
- Other children who are not related to me (or my partner) (e.g. roommate's children)
- My parents and/or my in-laws
- Roommates
- Other adults related to me (or my partner)
- Other adults who are not related to me (or my partner)
- Other
Currently, what is your highest level of education completed?*
- Less than High School
- Some High School
- GED
- High School Diploma
- Technical School (Not complete)
- Technical School (Complete)
- Certification Program (partial/ not complete- i.e. CNA, MA, Vet Tech, CDA, PTT, ect.)
- Certificate Program (Complete- Diploma)
- Associate Degree (Not complete)
- Associate Degree (Complete)
- Bachelor's Degree Program (Not complete)
- Bachelor's Degree (Complete)
- Other
If applicable, will you pursue the High School Equivalency (HSE) diploma during the one-year training?
- Yes
- No
- Maybe
Have you already begun your technical certification program at Maricopa Community College?*
- Yes
- No
If yes, which technical certificate are you pursuing?

*Required
Children
This section asks questions about your children, their ages, their school status, etc.
Do you identify as a single mother?
- Yes
- No
How many children do you have and what are their ages? (For example: 3 children ages 6mos, 2 yrs and 3 years)*
How many of your children are currently attending K-12 school?*
How many of your children are too young to attend K-12 school?*
How many of your children attend an early childhood education program/ facility?*
What is the name of the childcare facility your child/ children attend?*
Do you receive a scholarship or DES subsidy for their childcare?*
- Yes
- No
- Other
How many of your children are 18 years old or older?*
How many of your children currently live in your home?*
Who normally provides care for your child(ren)? (Check all that apply)*
- Yourself
- Family Member
- Friend
- Neighbor
- Childcare Center
- Head Start
- Pre-K
- K-12 School
- Before/ After School Program
- Other Community Resource (List in next question)
- No childcare necessary due to age of children
- Other
If you entered "Other Community Resource" or "Other", please list that solution below:
Who/ what is available as back up childcare if your typical option is unavailable?*
- Yourself
- Family Member
- Friend
- Neighbor
- Childcare Center
- Head Start
- Pre-K
- K-12 School
- Before/ After School Program
- Other Community Resource (List in next question)
- No childcare necessary due to age of children
- Other
If you entered "Other Community Resource" or "Other", please list that solution below:

*Required
Finances
Are you currently receiving a child care subsidy or scholarship that helps pay for your child(ren)'s care?*
- Yes, from DES
- Yes, from DCS
- Yes, through Quality First Scholarship
- Yes, directly from childcare facility
- No
- Not necessary due to child/ children's age
- Other
If you answered "other" to the above question, please list here:
How important would the child care benefit be to making it possible for you to attend classes?*
**One benefit of the Pathways program is support for finding and paying for a child care provider to care for your young child(ren) (under age 6) while you attend classes.**
- Extremely important
- Somewhat important
- Neutral
- Somewhat not important
- Not at all important due to child/ children's age
Do you currently receive SNAP benefits?*
- Yes
- No
- Unknown
Do you currently receive TANF benefits?*
- Yes
- No
- Unknown
If you answered "Yes" to the above question, what is the name of your TANF case manager?
TANF Case Manager Email
Do you currently receive any other state benefits?*
- Yes
- No
If yes, please describe*
What is your current employment status?*
- Employed full-time
- Employed part-time
- Gig work (Door Dash Driver, Uber Driver, etc.)
- Self Employed
- Unemployed/ Seeking Employment
- Unemployed and Not Seeking Employment (i.e- Stay at Home Mom)
If you selected "Self-Employed" please describe your work:*
Wages: How much income do you typically earn monthly from employment?*
Please answer as best you can. An estimated guess is fine. Indicate per week, per month, or per year. If not applicable, please indicate "0."
What is the estimated amount of dollars you receive from any other form of income? (Child support, social security, disability benefits, etc.)*
**Please answer as best you can. An estimated guess is fine. Indicate per week, per month, or per year. If not applicable, please indicate "0."**

*Required
Transportation and Housing
Do you have access to a vehicle in good, working condition?*
- Yes, I have a reliable vehicle for my own use.
- Yes, but I share this vehicle with other people.
- No, I have a vehicle but it is not working right now.
- No, I do not have a vehicle right now.
- Other
What forms of transportation do you use to get around? (check all that apply)*
- Driving my own vehicle
- Ride the bus/ streetcar
- Uber/ Lyft/ ride share
- Ride from friend/ family
- Bike
- Walk
- Other
Which methods of transportation would you use as a backup to your current transportation if it became unavailable?*
- Driving my own vehicle
- Ride the bus/ streetcar
- Uber/ Lyft/ ride share
- Ride from friend/ family
- Bike
- Walk
- Other
What is your current housing situation?*
- Rent
- Own
- I am currently unhoused
- I currently reside in a shelter
- I stay at the homes or friends and family but nowhere permanent
- Hotel/ Motel
- Other
How long have you stayed in the place where you are currently living?*
- One week or less
- More than one week but less than a month
- More than 3 months, but less than a year
- One year or longer
Do you feel your current living situation is stable?*
- Yes
- No
- Unsure
Are you comfortable with the amount of food you and your family have access to?*
- Yes
- No
- Not always
Do you receive WIC or other supplemental benefits to assist with your family's food stability?*
- Yes
- No
- No, but I would like information on available resources to assist with this.

About You and Your Goals
What are your education goals?
What are your career goals?
What motivates you to return to school at this time?
What are 3 things you would like us to know about you, your children and your family that might help us assist you?

*Required
Agreements and signature:
Signature (First Name, Middle Name, Last Name*
Today's Date (MM/DD/YYYY)*
You can print a copy of your answer after you submit

Applicant's First Name

Applicant's Middle Name (Initial)

Applicant's Last Name

Applicant's Last 5 Numbers of SSN

Applicant's Date of Birth

Phone

Email

Street Address and Apartment/Unit Number (If Applicable)

City

State

Postal Code

How did you hear about the Pathways Program for Single Moms? (If you were referred by someone, please list it here)

Please select the race/ethnicity that you identify with:

African AmericaAsianCaucasianHispanicLatinoNative AmericanPacific IslanderMultiple/MixedOther

Race/Ethnicity Other:

Is English your second language?

YesNo

What language(s) do you use most prominently? (If multiple, please list all)

Are you a United States Veteran?

YesNo

Veteran status:

VeteranService-Disabled VeteranMember of the ReserveMember of the National Guard

Do you identify as having a disability?

YesNoNot Sure

Do you have any felony convictions?

YesNo

Conviction Type(s):

Conviction Final Discharge?

YesNo

Which best describes your marital status?

SingleMarriedSeparatedDivorcedWidowed

Who lives in your household? (Check all that apply):

My romantic partner/spouseMy own childrenOther children who are related to me (or my partner) (e.g. nieces, nephews, cousins)Other children who are not related to me (or my partner) (e.g. roommate's children)My parents and/or my in-laws

What is your highest grade completed?

Currently, what is your highest level of education completed?

H - High School DegreeF - No Formal EducationN - No DegreeG - GEDO - OtherA - Associates DegreeC - BA/BS DegreeM - Masters Degree

If applicable, will you pursue the High School Equivalency (HSE) diploma during the one-year training?

YesNoMaybe

Have you already begun your technical certification program at Maricopa County Community College?

YesNo

If yes, what technical certificate program are you pursuing?

Do you identify as a single mother?

YesNo

Please click "Add another response" to add all additional children's information

Child's First Name

Child's Last Name

Child's Birthdate

How many of your children are currently attending K-12 school?

How many of your children are too young to attend K-12 school?

How many of your children attend an early childhood education program/ facility?

What is the name of the childcare facility your child/ children attend?

Do you receive a scholarship or DES subsidy for their childcare?

YesNoOther

How many of your children are 18 years old or older?

How many of your children currently live in your home?

Who normally provides care for your child(ren)? (Check all that apply)

YourselfFamily MemeberFriendNeighborChildcare CenterOther

If "Other", please list that solution:

Who/what is available as back up childcare if your typical option is unavailable

YourselfFamily MemeberFriendNeighborChildcare CenterOther

If "Other", please list that solution:

Are you currently receiving a child care subsidy or scholarship that helps pay for your child(ren)'s care?

Yes, from DESYes, from DCSYes, through Quality First ScholarshipYes, directly from childcare facilityOtherNo

If you answered "Other" to the above question, please list here:

How important would the child care benefit be to making it possible for you to attend class?

Extremely importantSomewhat importantNeutralSomewhat not importantNot at all important due to child/children's age(s)**One benefit of the Pathways program is support for finding and paying for a child care provider to care for your young child(ren) (under age 6) while you attend classes.**

Do you currently receive SNAP benefits?

YesNoUnknown

Do you currently receive TANF benefits?

YesNoUnknown

Do you receive any other state benefits?

YesNo

If yes, please describe?

Are you currently employed?

YesNo

Employment Information

Employer Name

Employer Street Address

Employer City

Employer Zip Code

Job Title (Position)

If "Self-Employed" please describe your work:

Are you Full Time or Part Time?

Full TimePart Time

Hourly Pay

How many hours a week do you work?

Does you employer provide Insurance Benefits?

What is your monthly income?

What is the estimated amount of dollars you receive from any other form of income? (Child support, social security, disability benefits, etc.)

**Please answer as best you can. An estimated guess is fine. Indicate per week, per month, or per year. If not applicable, please indicate "0."**

Do you have access to a vehicle in good, working condition?

Yes, I have reliable vehicle for my own use.Yes, but I share this vehicle with other people.No, I have a vehicle but it is not working right now.No, I do not have a vehicle right now.Other

What forms of transportation do you use to get around? (check all that apply)

Driving my own vehicleRide the bus/ streetcarUber/ Lyft/ ride shareRide from friend/ familyBike

Which methods of transportation would you use as a backup to your current transportation if it became unavailable?

Driving my own vehicleRide the bus/ streetcarUber/ Lyft/ ride shareRide from friend/ familyBike

What is your current housing situation?

Living in a place that you ownLiving in a place that you rentLiving in publicStaying in a shelterStaying with a friend/relativeOther

How long have you stayed in the place where you are currently living?

One week or lessMore than one week but less than a monthMore than 3 months, but less than a yearOne year or longer

Do you feel your current living situation is stable?

YesNoUnsure

Are you comfortable with the amount of food you and your family have access to?

YesNoNot Always

Do you receive WIC or other supplemental benefits to assist with your family's food stability?

YesNoNo, but I would like information on available resources to assist with this.

What are your education goals?

What type of certification(s) are you interested in completing?

Applied TechnologyBusiness, Entrepreneurialism, and ManagementComputer and Information TechnologyEducationHealth Sciences

Applied Technology areas of interest (select all that apply):

Automated Industrial TechnologyOSHA Safety TrainingSemiconductor TechnicianJ-Standard Soldering

Business, Entrepreneurialism, and Management areas of interest (select all that apply):

Banking and FinanceEntrepreneurial StudiesSmall Business ManagementSmall Business Start-Up

Computer and Information Technology areas of interest (select all that apply):

Amazon Web Services CloudCisco Network AdministrationCompTIA A+. Network +, Security +Database DevelopmentNetwork Support

Education areas of interest (select all that apply):

Early Childhood Education

Health Sciences areas of interest (select all that apply):

Certified Nursing AssistantCommunity Health WorkerEmergency Medical TechnicianLaboratory AssistantMedical Administrative AssistantMedical Billing and CodingPatient Care Associate/Health Unit CoordinationPractical Nursing

What are your career goals?

What motivates you to return to school at this time?

What are 3 things you would like us to know about you, your children and your family that might help us assist you?

Contact Information

Dress for Success Phoenix | 1024 E. Buckeye Road, Suite 165 | Phoenix, AZ 85034 | 602-489-7397

© 2022 Dress for Success

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