OPIOIDS

Answer questions completely except for those which do not apply. Information is kept confidential. By enrolling in this program, I grant permission to share my information with the Maryland Department of Labor. This program reserves the right to check the accuracy of the information below.


SECTION I: PERSONAL INFORMATION


























Can you provide one of each of the following documents:

  • a. Valid Driver’s License/State ID
  • b. Birth Certificate/Passport/Green Card/Voter’s Registration Card/DD214 form
  • c. Social Security card
  • d. Proof of address (indicated within Baltimore City on ID, bill, etc)



SECTION II: EDUCATIONAL BACKGROUND




SECTION III: EMPLOYMENT INFORMATION


Please provide your current or most-recent employment information.








Additional Skills/Abilities




SECTION IV: EMERGENCY CONTACTS



















SECTION V: CONSENT

This program is funded by the State of Maryland’s EARN Maryland Grant Program, administered by the Maryland Department of Labor. As a recipient of EARN Maryland funds, this program is required by law to collect certain demographic information from training participants and to provide such information to Labor for reporting purposes. Any demographic information provided to Labor will not contain personal identifiable information. By enrolling in this program, I grant permission to share my demographic information with Labor. I understand and agree with these conditions.


Affirm that you or someone close to you has struggled with addiction, whether it be from opioids or otherwise.