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Arkansas CiviForm
Note: Fields marked with a * are required.
Date of Birth (mm/dd/yyyy) *
Example: January 5, 1998 would be 01/05/1998.
Are you a veteran or active duty service member or their spouse? *
Veteran
Active Duty
Spouse of a Veteran
Spouse of an Active Duty Service
None of the Above
Are you an American Indian, Alaskan Native, Native Hawaiian, or Other Pacific Islander? *
Yes
No
Do you have a disability that impacts any of your major life activities? (Work, School, Activities of Daily Living, etc.) *
Yes-Vision Related
Yes-Other
Do you have a job? *
I have a job.
I have a job, but want a better job.
I have a job, but have been told I am getting laid off.
I don't have a job, but I want a job.
I don't have a job, and I don't want a job.
I am disabled and unable to work.
Are you currently enrolled in school? *
Yes, I am in high school or lower.
Yes, I am in an alternative school.
Yes, I am in college or community college working on a degree.
Yes, I am attending Adult Education (No High School Diploma or GED)
No, I graduated high school or have a GED
No, and I dropped out of high school and don't have a high school diploma or GED.
No, but I am legally required to be either because my age or court order..
What was the last grade you finished in school? *
Do you need help with your English, reading, writing, math, or other academic skills? *
Examples include: you have a problem counting change when you buy something, can't pass a drivers test in English, problems reading instructions in English, problems following spoken instructions in English, English Language Learner, etc.
I don't know
Are you or your family low-income? *
Examples include: Income below the poverty line or, receiving Medicaid/ARKids, SNAP/Food Stamps/EBT, TANF, HUD, SSI, SSDI, Free/Reduced Lunch, or are Homeless/Runaway, etc.
I am not sure
Do you or your family move around for farm work or seasonal work? *
Are you currently or have you in the past been involved with the criminal justice system? (Arrested, convicted, in prison or jail, on parole or probation, etc.) *
Involvement with the criminal justice system does not prevent you from possibly being eligible for services, it is asked to identify the various barriers you may be facing. Additionally, there may be programs that can assist justice involved people.
Do you need help getting into or completing an education or training program, or getting or keeping a job? *