Participant Form - Senior Community Service Employment Program
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1
2
3
4Type of Action
(Check one)
Enrollment, Regular SCSEP
ARRA Grant Enrollment
Ineligible, referred
Placed on waiting list
_____/_____/_______
Update
MM
DD
YYYY
Fields marked with
indicate a data validation field
____/______/_______
MM
DD
YYYY
You must answer all questions. SSAI will not accept
(
.)
Circle the number that has new information
blank responses.
Direct transfer
Reassignment. Code of former SSAI
subgrantee:
____ ____ ____
National Grantee Code 158
Senior Community Service Employment Program
____/_____/______
Reassignment date
Participant Form
MM
DD
YYYY
Issued July 2009
A:
Identify the Project
the Project
A:
Identify
Is the participant at risk of homelessness?
9.
Yes
__________________________
Document used to verify
Application date
______/______/________
1.
No
MM
DD
YYYY
________________________________
Project subgrantee
2.
Telephone (_______) ______________–_____________________
10.
No telephone
_________________
Project number
3.
Participant’s email address (optional):
11.
B B : :
Learn About
About the Participant
the Participant
Learn
___________________________________________________
_____________________________________________
Name
4.
First
Middle Initial
Last
Social Security number ________–______ –_________________
12.
Mailing address
5.
Emergency contact _____________________________________
13.
First
Last
___________________________________________________
Number
Street
Apt./PO. Box
__________________________
Relationship to the participant
14.
___________________________________________________
City
State
ZIP code
Contact telephone (_______) __________ –_________________
15.
County _________________
Urban or Rural (circle one)
6.
C:
C:
Determin
Determin e e if the Participant Is
if the Participant Is Eligibl
Eligibl e e
(automatically validated)
Birthdate
_____/____/______
__________________________
16.
State of residence
________
_____________________
7.
MM
DD
YYYY
Document used to verify
State
Documents used to verify
Age ______
17.
Is the participant homeless?
Yes
________________
8.
Document used to verify
No
________________________________________________________
Participant’s name
Participant Form /
page 1
First
Middle Initial
Last
ARRA 2009
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