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Contact Information
Name
*
First
Last
Last 4 of SSN
*
Residential Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address
*
Same as residential
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Homeless or Couch Surfing
Email
*
Phone
*
Alternate Contacts
List two individuals who know how to reach you. Select friends or family members you have known for more than 5 years.
Contact #1 Name
*
Relationship
*
Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Contact #2 Name
*
Relationship
*
Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Demographic Data
Date of Birth
*
Month
Day
Year
Age
*
Registered for Selective Service
*
Yes
No
Documented Exemption
Not Applicable
Authorization to Work
*
U.S. Citizen
Permanent Resident
Alien/Refugee Lawfully Admitted
None of the Above
Employment
Are you currently employed?
*
Yes
No
Do you receive Unemployment Insurance?
*
Yes
No
Jobs that interest you
*
Volunteer experience
*
Clubs, youth groups, and/or team sports that you enjoy
*
How do you like to spend your free time?
*
Education
High School Diploma or Equivalent
*
Yes
No
Current School Status
*
In school
Not attending school
What was the last grade you completed?
*
Please enter a number from
1
to
12
.
Enter a number 1-12
Are you planning to attend school next term?
*
Yes
No
Favorite subjects
*
Schools and Programs of Interest
*
Degrees/Certificates Received
List any degrees/certificates received
Special skills/abilities
Goals
In your future career would you like to
*
Make things
Help people
Create beauty
Organize things
Explore ideas
Work outside
Perform physical tasks
Take responsibility
Improve society
Help animals
Improve the environment
Experience variety
Check as many as you would like
What are your future career goals?
*
What are your future educational goals?
*
Why are you interested in this program?
*
Public Assistance
Are you receiving, or in the past 6 months have received, the following:
(Mark "Yes" if you are a member of a family that is receiving, or in the past 6 months has received public assistance)
Temporary Assistance for Needy Families
*
Yes
No
General Assistance
*
Yes
No
Supplemental Nutrition Assistance Program
*
Yes
No
Pell Grant
*
Yes
No
Barriers to Employment
English Language Learner
*
Yes
No
Homeless
*
Yes
No
Involved with the Criminal Justice System
*
Yes
No
Involuntarily Released From Employment
*
Yes
No
Transportation Issues
*
No transportation
No auto insurance
Suspended driver's license
Need vehicle repairs
Moving violations (past 3 years)
DUI offenses (past 10 years)
Unpaid tickets
None
Check all that apply
Legal Issues
*
Criminal record (Misdemeanor)
Criminal record (Felony)
Criminal record (Record sealed or expunged)
Probation/Parole
Pending legal issues
Overdue child support payments
None
Check all that apply
Family Issues
*
Lack of childcare
Lack of family support
Housing problems
Must move soon
Single parent
In foster care
Aged out of foster care
None
Check all that apply
Financial Issues
*
Financial problems
Heavy debts
Outstanding student loans
Separation/Divorce
Unable to meet basic needs (food/clothing)
Drug and alcohol problems
Family violence
None
Check all that apply
Financial
Complete the following table. Include all of the individuals in your household.
Income
*
Name
Relationship to You
Age
Gross Income (past 6 months)
Income Source
Included as Family Income
Wages/Tips/Salary/Commissions
Self-Employment
Railroad Retirement
Strike Benefits
Workers’ Compensation
Training Stipends
Alimony
Private Pensions
Government Employee Pensions
Military Retirement Pay
State Disability Insurance*
Scholarships (not needs-based)
California Promise Grant – AB19
Gambling or Lottery Winnings
Severance Pay
Terminal Leave Pay
Social Security Disability Insurance*
Wages from CA Conservation Corps
Unemployment Insurance
Child Support Payments
Social Security Old Age Insurance
*see confidential questionnaire
Excluded from Family Income
Needs-based Public Assistance
TANF, SNAP, SSI, RCA, GA
Pell Grants
Needs-based Scholarships
Loans
California College Promise Grant
Veteran Benefits
Income from Active Military Duty
Capital Gains
Bank Withdrawals
Sale of House/Car/Property
Tax Refunds
Gifts
Lump-sum Inheritances
One-time Insurance Payment
Insurance Compensation for Injury
Non-cash Benefits from Employer
Medicare/Medicaid
Confidential Health/Medical Information
Do you experience a disability?
*
Yes
No
I do not wish to disclose
Category of Disability
*
Physical/Chronic Health Condition
Physical/Mobility Impairment
Mental or Psychiatric Disability
Vision-related Disability
Hearing-related Disability
Learning Disability
Cognitive/Intellectual Disability
Check all that apply
In your own words, please describe your disability or the accommodations you may need
*
Are you a disabled veteran?
*
Yes, Disabled
Yes, Special Disabled (greater than 30%)
No
Have you received services from Veterans Vocational Rehabilitation?
*
Yes
No
Unknown
Do you receive Supplemental Security Income (SSI)?
*
Yes
No
Monthly Amount
*
Do you receive Social Security Disability Income (SSDI)?
*
Yes
No
Monthly Amount
*
Are you a Ticket to Work beneficiary?
*
Yes
No
Unknown
Single Parent
*
Yes
No
Includes Single Pregnant Women
Pregnant or Parenting
*
Yes
No
Who is your Case Manager?
*
Darlene
Jan
Jessica
Lori
Sara P.
Sarah D.
Steve
Tammy
Lesley
I don’t know
Voluntary Media Release
I consent to the use of my quotes and photographs. I grant Golden Sierra Job Training Agency the right to edit and use such products for the purpose of creating a participant testimonial for use in print and online media. I hereby release Golden Sierra Job Training Agency and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
Consent
*
I agree
I do not agree
Release of Information
Consent
*
I agree
This release is a voluntary consent that allows Golden Sierra Job Training Agency to make employment inquiries, obtain records, and/or enter into discussions with other organizations. I understand the information released will be used in order to assess, plan, and facilitate the delivery of services for my benefit. I hereby authorize my training provider to release academic records such as attendance, grade reports, and graduation status. In addition, I give permission to Golden Sierra Job Training Agency to contact my current and former employers in order to verify my employment status (i.e. start date, job title, hourly wage, and hours per week). This release will expire 3 years from the date of signature. I hereby certify that I have read and received a copy of this release.
Certification
Consent
*
I agree
I certify that the information provided in this questionnaire is true and correct. I am aware that this information will be used to help determine my eligibility for career and training services. I understand eligibility for services does not constitute an entitlement to services.
Phone
This field is for validation purposes and should be left unchanged.
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