Email Address
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Password
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Minimum 8 characters
First Name
Gender
Please Select... Male Female Other
Ethnicity
Please Select... Haitian Hispanic or Latino None of the above I do not wish to answer
Race
Please Select... American Indian/ Native American Asian Black/African American Hispanic/Latino White/Caucasian Pacific Islander Other
Race If selected other for, race?
Veteran Status
Please Select... Yes No N/A
What county do you live in?
Please Select... Brooks Columbia Gadsden Hamilton Jefferson Lafayette Leon Lowndes Madison Suwannee Taylor Thomas Wakulla Other
If selected other for, what county do you live in?
Are you between the ages of 16-24?
Please Select... Yes No
Language
Please Select... English Spanish Other
If selected other for, language?
Are you registered in Employ Florida?
Please Select... Yes No
Have you received services from Vocational Rehabilitation (VR) during the last 90 days?
Please Select... Yes No
Have you received services from Division of Blind Services (DBS) during the last 90 days?
Please Select... Yes No
Have you received services from Adult Education (GED class) during the last 90 days?
Please Select... Yes No
Have you received services from Suwannee River Economic Council (SREC) during the last 90 days?
Please Select... Yes No
Have you received services from Older Workers (NCBA) during the last 90 days?
Please Select... Yes No
Have you received services from Capital Area Community Action Agency (CACAA) during the last 90 days?
Please Select... Yes No
Have you received services from Big Bend Technical College (BBTC) during the last 90 days?
Please Select... Yes No
Have you received services from North Florida College (NFC) during the last 90 days?
Please Select... Yes No
Have you received services from RiverOak Technical College (RTC) during the last 90 days?
Please Select... Yes No
Have you received services from Department of Corrections (Probation/Parole) during the last 90 days?
Please Select... Yes No