AlongTheWayPa -

Client Application

If you are experiencing issues with submitting your application, please contact Michael@alongthewaypa.org

This application is to apply to either the Career Climb or Child Care to Work programs.

Full Name *

Cell Phone *

Home Phone

Email *

Preferred Method of Contact *

Phone Call

Email

Text

Partner Referral Code (If you have received one from another Community Based Organization)

Program of Interest

The Career Climb Program is best suited for parents looking to complete a workforce development program in order to either begin a career pathway OR advance in their current career pathway.

The Child Care to Work program is best suited for parents that are working a livable wage job and are in a secure career pathway that need support with filling in child care gaps (i.e. before and after school child care, school closure child care, summer child care). Applicants will need to be able to afford a $16/hr co-pay.

Which Along The Way program are you applying to? *

Demographics

Birthday *

Marital Status *

Are you a single mother? *

Gender *

Race *

Ethnicity *

Have you ever been involved with the criminal legal system?

Yes

No

Prefer not to say

DISCLAIMER: To help secure funding that supports this program, we collect additional information such as criminal background status and insurance coverage. This information is collected for grant reporting only and does not impact your eligibility for services. You may choose not to answer these questions. Your choice will not affect your application.

Consent: Criminal Background Status *

I agree to provide my criminal background status for grant reporting purposes.

I do not wish to provide my criminal background status at this time.

Housing

Address *

Line 2 *

City *

State *

Zip *

Residence County *

Current Living Situation *

Household Size

Describe household size *

Ages of children *

Health Insurance

What is your health insurance provider? *

Independence Blue Cross Blue Shield: Keystone

United healthcare

Geisinger

Aetna

First Priority Health

PPO, HMO, other plan (please specify)

Uninsured

Specify Here

Disclaimer: At this time, Along The Way does not bill health insurance for any of our services. However, the state of Pennsylvania is exploring potential expansions of Medicaid benefits that could, in the future, include services like those Along The Way provides. While there is no immediate change, and Pennsylvania has not yet introduced any formal plans to cover our services, we are proactively collecting health insurance information to be prepared for any potential updates. By gathering this information now, we aim to ensure that if such changes occur, we can quickly and efficiently provide expanded services to eligible families. Thank you for your understanding and cooperation as we work to support our clients' holistic well-being.

Visit this website to learn more: https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/

To help secure funding that supports this program, we collect information such as health insurance coverage. This information is collected for grant reporting only and does not impact your eligibility for services. You may choose not to answer. Your choice will not affect your application.

Consent: Health Insurance Coverage *

I agree to provide my health insurance coverage information for grant reporting purposes.

I do not wish to provide my health insurance coverage information at this time.

Estimated Monthly Income

Monthly Income *

Employment Status

Employment Status *

Do you plan to be with this employer for a long period of time? *

Yes

No

Do you have reliable transportation? *

Yes

No

How did you hear about us? *

If you heard about us from an employer/agency/other; write their name below

Disclaimer: To keep our programs accessible to the community, we sometimes need to share general information with funders about the people we serve—like common challenges or needs. This helps us secure funding that makes our services possible.

We only share this information in a way that protects your privacy. It is grouped together with information from other clients and is never connected to your name or personal details.

You may choose not to provide this information. Your choice will not affect your application.

Consent: Other Grant-Related Information *

I agree to provide other grant-required information for grant reporting purposes.

I do not wish to provide other grant-required information at this time.

If you are experiencing issues with submitting your application, please contact Michael@alongthewaypa.org