Senior Community Service Employment Program Participation Form

Senior Community Service Employment Program Participation Form - Alaska

SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM

ALASKA COMMISSION ON AGING

PO BOX 110209

JUNEAU AK 99811-0209

Intake & Assessment

GRANTEE: _______________________

GRANT# ___________________

PARTICIPANT INFORMATION

First Name

Middle Name

Last Name

Social Security Number

Date of Birth (mo/day/yr)

Age

Male

Female

Mailing Address (street, city, zip)

Phone Number

EDUCATION

ETHNIC GROUP

grade or less

Caucasian

! Black

-11

!High school or GED

! Hispanic

!1-3 yrs college

! American Indian/Alaska Native

!4+ yrs college

! Asian/Pacific Islander

Disabled? Yes ! ! ! ! No! ! ! !

Veteran? Yes ! ! ! ! No! ! ! !

Longevity Bonus? Yes ! ! ! ! No! ! ! !

Public Assist? Yes ! ! ! ! No! ! ! !

Head of Household? Yes ! ! ! ! No! ! ! !

Social Security? Yes ! ! ! ! No! ! ! !

BACKGROUND: Employment, Training and Education

Vocational training (include military) Yes ! ! ! ! No ! ! ! ! Certificate or License? Yes ! ! ! ! No! ! ! !

College Credits? Yes ! ! ! ! No ! ! ! !

Name of College_____________________________

Dates attended

Major

Degree

Valid Driver’s License? Yes ! ! ! ! No ! ! ! !

Occupational Licenses? Yes ! ! ! ! No ! ! ! !

List equipment, tools, and office equipment you can operate.

________________________________________________________________________________________

Do you have any volunteer/unpaid work experience? Yes ! ! ! ! No ! ! ! !

Organization Name

Dates

Hours/week

Skills Used

Hobbies/Interests:

________________________________________________________________________________________

C:\Program Files\Adobe\Acrobat 4.0\Acrobat\plug_ins\OpenAll\Transform\temp\Intake.doc

Senior Community Service Employment Program Participation Form - Alaska

Related Articles

Related forms

Related Categories