New Member Registration

Alternate Phone Number

Do you live in Public Housing or receive Section 8 assistance?

Yes No

If yes, what is the Site and Unit #?

Education

Please list your educational history.

College | Trade School

Family Composition

Please list all family members including yourself.

Do You Receive or Have You Received the Following:

If other, please specify.

Emergency Contact

Add the name and information of your emergency contact(s).

Campus of Hope Virtual Village Participation: I agree to permit the Housing Authority Birmingham District (HABD) and its partners to use information, as well as images of me and my family as participants. This includes internal and external promotional materials and additional information as needed. This also includes any broadcast, printed advertising, printed materials and promotional video on HABD and its partners’ websites. Lastly, it includes sharing of participant information between HABD and its partners.

Campus of Hope
Virtual Village Participation

Under each section, check the box that applies.

Areas of Need (select all that apply)

Educational Plans (select all that apply)

Employment

Please detail your employment information below.

Are you currently employed?

Yes No

*If YES, answer the following:

Company:

Do you have a drivers license

Yes No

Do you want help finding a job?

Yes No

Do you have any barriers that keep you from employment?

Yes No

If yes, please explain.

Do you have reliable transportation?

Yes No

Did your job lay you off because of the current Coronavirus Pandemic?

Yes No

If yes, please detail when.

Virtual Village Questionnaire

Job Training / Section 3

1. Are you currently enrolled in a job training program?

Yes No

2. Are you interested in vocational training?

Yes No

1. Do you have a high school diploma or GED?

Yes No

2. Would you like to attend a Trade School, College or GED program?

Yes No

1. Do you need childcare in order to work or attend school?

Yes No

2. Would you be interested in taking a Parenting Skills class?

Yes No

3. Would you like to enroll your child in a Mentoring Program or afterschool program?

Yes No

Virtual Village Questionnaire

1. Would you be interested in speaking to a counselor?

Yes No

2. Would you be interested in substance abuse counseling?

Yes No

3. Would you be interested in family counseling?

Yes No

4. Do you need to see a doctor or dentist?

Yes No

Finances / Homeownership

1. Would you like to own your own home?

Yes No

2. Are you interested in the HABD Homeownership Program?

Yes No

3. Would you be interested in credit repair and/or credit counseling?

Yes No

Section 3 / Construction Skills

Do you have experience in the following?

Would you like to share any additional comments?

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