Services for: Individuals & Families | Employers | Funders & Partners

CARES of Washington Application Form

Please fill out the following form to the best of your ability. We are just looking for basic information about you or the individual in need. When finished, click the Submit button, and someone from CARES will contact you within two business days (Saturday and Sunday excluded). If you are unable to finish the form, the information provided will have to be entered again on your next visit.

In order to be eligible for any CARES employment programs, one or more of the following must be applicable to you (or the individual you are applying on behalf of):

• Individual with a disability and are currently unemployed
• Currently receiving or have received SSI or SSDI
• Have been a claimant with Labor and Industries or Workers Compensation
• Have a learning disability (or may have that is currently not diagnosed)
• Have received services from Vocational Rehabilitation services including DVR or DSB;
• Have received drug and alcohol treatment
• Had a stroke, HIV, mental disability, or any other form of physical or mental
disorder.

Name:

Date Of Birth:

Street Address:

City:

State:

Zip Code:

Home Phone:

Email Address:

Other Phone:

According to your State's Vocational Rehabilitation agency standards, is your disability
categorized as significantly disabled?: [Y/N]

How does your disability affect your ability to work?:

Who referred you to CARES of Washington?:

Have you been a participant of any State Vocational Rehabilitation or program?: [Y/N]

If So please supply counselor's name and phone number:

Do you or have you ever received SSI or SSDI benefits?: [Y/N]

What was your total earned income last week?: (Do not include SSI, SSDI, or public assistance)

Just before applying to CARES of Washington, how long were you unemployed?:

Work History: [ Copy and paste your work history in this section ]

Education: [If you have a document, copy and paste your education background in]

Primary career objective:

Other career interest:

Please list any special skills and/or equipment you can operate:

Minimum salary requirement:

Please specify what hours you are willing to work: [ F/T, P/T, PERM, TEMP ]

Transportation available to you:

Do you have any work-site preferences based on where you live (a particular county for example
or within a certain distance)?

The following questions are optional. They are useful to CARES of Washington for Equal Employment Opportunity reporting compliance, and are not considered as part of your application and are not related to your eligibility.

Have you ever been in a union?: [Y/N]

If so, what union?

Sex: [M/F]

Marital Status:

Ethnicity:

CONTACT US

Individuals & Families
King County:
Lisa Roy 206-938-1253
lroy@caresofwa.org

Kitsap County:
Tony Mendiola 360-443-8607
tmendiola@caresofwa.org

Pierce County:
Doug Stauffer 253-274-1479
dstauffer@caresofwa.org

Snohomish County:
Jacki LaLonde 206-938-1253
jlalonde@caresofwa.org