top of page

River Valley Resources

About Us
What We Do
Get Involved
- Early Literacy
- Taste of the Town 2026
News
Contact
Search
More...

Use tab to navigate through the menu items.

Rural Works

Application

Staff assigned:*

Participant Information:

Application date:*

Site location:*

Social security number*

Participant information:*

First name*

Last name*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Phone*

Email*

Birthday*

Month

Day

Year

Do you have an Indiana ID:*

Yes

No

Demographics/Eligibility

Gender:*

Male

Female

Ethnicity:*

Hispanic (Cuban, Mexican, Puerto Rican, Central American or Spanish cultural origin

Other

Race:*

Black

Pacific Islander

White

Asian

Native American

U.S. Citizen:*

Yes

No

Veteran Status*

Disability Status:*

English Language Learner:*

Yes

No

Education level:*

Employment status of enrollment:*

Justice-involved status (if applicable):

Medicaid eligible-self attestation:*

Yes

No

Unsure

Declined

Date of Medicaid Self Attestation:

Barriers (check all that apply)*

Transportation

Childcare

Technology/Digital Access

Identification/Documents

Criminal Record

Financial Barriers

Housing

Food Insecurity

Education/HSE

English Language

Other

Are you interested in apprenticeship opportunities that will lead to employment?*

Yes

No

Have you been told you are not allowed a rehire with a particular employer?*

Yes

No

If so, who:

Do you have a resume:*

Yes

No

Do you know your work history and dates of employment?*

Yes

No

Do you need referral information for mental health, anger management, or alcoholism/drug treatment?*

Yes

No

Can you pass a pre-employment drug screen?*

Yes

No

What is your goal for participation in Rural Works?*

Other information your case manager needs to be aware of to graduate you from Rural Works and assist with the next step whether that be skill training, post secondary, or employment:*

Right to Privacy: I understand that the information requested from me will be used by River Valley Resources, Inc. to determine what barriers I may face as I seek employment and to determine eligibility for the program. Such personal information will not be shared with any other agencies or potential employers without my written permission on a separate release.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date:*

Helping meet the needs of those who need it most.

Email: info@rivervalleyresources.com

Phone: 812-265-2652

Toll-Free: 855-591-7848

Fax: 812-265-2664

Address:

100 E. Second Street

Madison, IN 47250

Quick Links

Contact Us

First name*

Last name*

Email*

Phone*

County:*

Select a program:

Which age group do you fall under:*

Youth

Adult

Senior

Type Your Message Here *

© 2026 by River Valley Resources, Inc. a not-for-profit, section 501(c)(3).

bottom of page