Participant Form - Senior Community Service Employment Program Page 4
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Services to veterans
F F : :
First Community Service Assignment
First Community Service Assignment
Medical support
Adult daycare
________________________________________
Host agency
47.
Library programs
Name
Museum and cultural institutions
___________________________________________________
Tourism and visitor centers
Number
Street
Apt./PO. Box
Public works and transportation
___________________________________________________
Emergency preparedness and response
City
State
ZIP code
Energy and weatherization
Environment-related
Location of community service assignment, if different from 47.
48.
Home rehabilitation
Residential facilities / Temporary shelters
___________________________________________________
Subsidized housing
_ _ _ _ _ _ _ _ _
Federal Employer Identification No. (FEIN)
Other ___________________________________________
49.
Main function of host agency (Check only one.)
Type
Not-for-profit — 501 (c)(3)
59.
50.
Government (Check one.)
Services to the general community
Services to the elderly community
Federal
State
Education
Project administration
Local
Early childhood reading
Health
Adult literacy programs
Health assessments
Supervisor
Mr.
Health and hospitals
Medication management
51.
Ms.
Housing & home rehab
Home care
________________________________________
Employment assistance
Housing & home rehab
First
Last
Recreation, parks, & forests
Employment assistance
Environmental quality
Recreation/Senior centers
________________________________________
Title
Public works & transportation
Exercise & fitness programs
Social services
Nutrition programs
Supervisor’s telephone
(_______) __________ –_______________
52.
Services to teenagers
Home delivered meals
Services to children
Congregate meals
Supervisor’s email (optional)
53.
Services to veterans
Transportation
__________________________________________________
Services to disabled
Outreach/Referral
Immigration & refugee services
Legal
Supervisor’s site and mailing address, if different from 47. (Note:
54.
Legal
Financial
this is the person who will receive the survey, if applicable.)
Financial
Counseling
__________________________________________________
Counseling
Caregiver support
Name of Host Agency
Conservation
Caregiver counseling
Community betterment
Conservation
__________________________________________________
Number
Street
Apt./PO. Box
Library programs
Community betterment
Museums/Cultural institutions &
Other __________________
__________________________________________________
travel/tourism
________________________
City
State
ZIP code
Emergency preparedness &
Date this assignment started _______/______/_________
response
55.
MM
DD
YYYY
Other_______________________
____________________________
Hourly wage $ ______________
56.
Is the participant’s community service assignment “green”?
60.
Assignment title _______________________________________
Yes
No
57.
A “green job” is either any position with a non-profit or government agency
Of these programs, which best describes the participant’s
58.
that works on the environment or any position with a program that works on
community service assignment? (Check all that apply.)
the environment in a non-profit or government agency. Examples include:
Adult literacy programs
(a) receptionist for a weatherization program; (b) energy auditor with the
Red Cross; any positions with: (c) City/County recycling services or transit
Early childhood reading
services; (d) City/County environment departments; (e) Public parks/
Child daycare
preserves, wildlife refuges, conservation districts, hatcheries, agricultural
Services to children
centers; (f) “Outreach” on recycling, weatherization, energy efficiency; (g)
Services to disabled
Green spokesperson to schools, senior centers, etc. These examples are
Services to immigrants and refugees
not all-inclusive.
Services to teenagers
________________________________________________________
Participant’s name
Participant Form /
page 4
First
Middle Initial
Last
ARRA 2009
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Parent category: Business