KAPTIN Registration Form First Name(required) Last Name(required) Home Address(required) City(required) State(required) Zip Code(required) Phone Number(required) Email Address(required) Affiliated with an organization or a company? Yes No Name of affiliated organization or company Name of affiliated organization or company If you have more than two entities, please list the name of the affiliation below. How did you initially learn about Koreatown Empowerment Center? Website/Google Search Social Media or E-Newsletter Colleague or Friend Koreatown Empowerment Center Staff or Board Member Event/Training/Conference News Media (News Paper/Radio) Other Other (Please specify)(required) Do you have experience serving in bilingual?(required) Yes No Do you have experience in filing an online application?(required) Yes No What languages do you speak, write, and read fluently?(required) Gender Female Male Prefer To Self-Describe Prefer Not To Answer Please select your preference of the method of service. (required) By Phone By Email Please select your preference of day of the week for service. (Check all that apply) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Professional Skills and Experiences that you will bring to KAPTIN service opportunities ( Check all that apply) Social Services (Public Benefits) Unemployment Insurance Covid 19 Relief Programs for family and small business Substance Prevention and Counseling Suicide Prevention & Counseling Interpretation Assistance for Oncological hospital visit Other Other (Please specify) In one or two sentences, tell us why you are interested in joining KAPTIN?(required) Please enter your LinkedIn profile URL REGISTER Δ
