Senior Community Service Employment Program Participation Form

Senior Community Service Employment Program Participation Form - Alaska Page 5

1. What is your vocational goal?_________________________________________________

! Yes

! No

2. Have you been actively looking for work?

How long?_____________

3. What kind of work are you interested in? _________________________________________

4. What do you think is the main reason you have not found a job? ______________________

! Yes

! No

5. Are you signed up with the Employment Service?

! Yes

! No

6. Would your past employers give you a reference?

! Yes

! No

7. Do you have an updated resume?

! Yes

! No

8. Have you had a “bad” experience at work that has caused you to lose a job?

9. What shifts are you willing to participate in your work experience?

! Full-time

! Part-time

! Seasonal ! evenings/weekends ! night shifts

! Yes

! No

10. Does your family support your decision work/obtain training?

11. What are your regular sources of income? ________________________________________

12 How much money do you need to earn? __________________________________________

13. Are there any emotional or mental issues that might affect your ability to work and/or ability to

complete training? ! Yes

! No

CERTIFICATION

The information I have given is true to the best of my knowledge. I know that this information can be

reviewed and verified.

If asked, I will give proof to support this information.

In the even the

information in this application is found to be inaccurate, I may be removed form the program, and I

will be liable for all costs expended by SCSEP on my behalf. I give permission to SCSEP to release

information to other agencies to help me reach my employment goals. I also give permission for

school and/or other organizations to release information needed to SCSEP to help me reach my

employment goals. I understand that any information given is confidential.

_______________________________________

______________________

Participant Signature

Date

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

Senior Community Service Employment Program Participation Form - Alaska Page 5

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