Senior Community Service Employment Program Participation Form

Senior Community Service Employment Program Participation Form - Alaska Page 4

Resources and Needs

What are your reasons for coming to our office? Check all that apply.

! ESL/basic skills

! Computer training

! Other training

! Job leads

! Employment option

! Interview skills

! Resume

! Other _____________________________________________________

Are you currently working with or receiving assistance from any other agencies?

! One Stop _________

! Mental Health

! Corrections Department

! Senior Service Agency

! Drug & alcohol Problems

! Public Assistance

! Vocational Rehabilitation

! Housing

! Other _____________________

Please List the contact person and phone number for any agencies listed above.

Name: _________________________

Telephone Number _____________________________

Are you willing to sign a release of information so that we may exchange information with the

person(s) listed above? ! ! ! ! Yes ! ! ! ! No

Do you need assistance in the following categories?

! Housing

! Food

! Clothing

! Health

! Transportation

! Counseling/Mental Health

! Money Management

! Drug & Alcohol treatment

! Vision

! Hearing

! reading/writing

! Other _____________________

What types of assistance do you believe will most help you to reach your employment goals?

! learning new skill

! updating skills I already have

! help build my self-esteem

! help build my confidence

! learning to speak English

! obtaining a current work reference

! gaining recent work experience

! learning job search techniques

What describes your present situation?

! Unemployment less than 6 months

! Unemployment 6 months to 1 year

! Unemployment over 1 year

! employed part time/underemployed

! self-employed

! have not worked/none recently

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Senior Community Service Employment Program Participation Form - Alaska Page 4

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