Knoxville Area Urban League · KAUL General Intake Form

PRIVACY NOTICE

We do not share any of the information collected on this form with anyone other the intended counselor. Your information is secure and stored safely.

Contact Information

Name

*

First Name

Last Name

Email

*

Verify Email

*

Birthday

*

(mm/dd/yyyy)

Social Security Number

Phone (Home or Cell)

*

How do you prefer to be communicated with?

*

Check all that apply

Email

Phone

Text

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Demographic Information

Age Range

*

Gender

*

Marital Status

*

Ethnicity

*

Are you a registered voter?

*

Voter Registration Information

General Voter Registration Information-

Click here to register to Vote!

Races

*

Choose all that apply.

African American / Black: Origins in any of the Black racial groups of Africa.

Alaska Native / Native American: Origins in any of the original peoples of North, South, and Central America

Asian: Origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent

Caucasian / White: Origins in any of the original peoples of Europe, the Middle East, or North Africa.

Hawaiian / Pacific Islander: Origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Two or More Races: A person identifying with more than one specified racial category.

Prefer not to say: Choose not to disclose their racial identity.

Are you a U.S. Veteran?

*

Gross Monthly Income (If Applicable)

General Information

Do you have reliable Transportation?

*

Self-Identification of Criminal History Options

*

Annual Income Level

*

Education Level

*

How did you hear about KAUL?

*

Check all that apply

TV

Radio

Newspaper

Friends/Family

Walk-In

Social media/KAUL Website

Other

Have you received KAUL services before?

*

Which KAUL services have you received previously?

KAUL Services

Do you need Advocacy & Justice Services?

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RISE Re-Entry Program Expungement Clinic Information or Orientation

Which Advocacy and Justice services are you needing?

Expungement Clinic

Expungement Orientation

RISE & ReEntry

Do you need Economic & Business Development services?

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CoStarters, Opportunity to Prosper, Knoxville Black Business Directory, Level Up Skills Apprenticeship Program, NextLevel Knox

Which Economic and Business Development services are you seeking?

CoStarters

Opportunity to Prosper Knoxville Black Business Directory

Level Up Skills Apprenticeship Program

NextLevel Knox

Do you need Education and Youth services?

*

NAS program, Shoes for School, Education Policy, Scholarships and other education resources

Which Education and Youth services are you seeking?

NAS program

Shoes for School

Education Policy

Scholarships and other educational resources

Do you need Health services?

*

Cancer Support program, American Heart Association

Which Health services are you seeking?

Cancer Support program

American Heart Association

Do you need Housing services?

*

Ehome America, Financial Education Course, Foreclosure Workshop

Which Housing services are you seeking?

Homebuyer Education

Financial Education Course

Foreclosure Counseling

Rental and Utility Assistance

Do you need Workforce services?

*

Are you seeking employment?

Resume File Upload

Job level desired?

Entry Level

Mid-Level

Senior Level / Management

Specialist / Expert

Job salary range desired?

$25,000 - $30,000 per year

$30,000 - $40,000 per year

$40,000- $50,000 per year

$50,000- $60,000 per year

$60,000 and above