Questionnaire

Contact Information

Name(Required)

First Last

Last 4 of SSN(Required)

Residential Address(Required)

If homeless, enter primary nighttime address

Street Address Address Line 2 City State ZIP Code

Mailing Address(Required)

Same as residential

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Alternate Contact

Name

Phone

Relationship

Financial

Complete the following table. Include all of the individuals in your household.

Family size(Required)

The total number of children and adults (related by blood, marriage, or decree of court) currently living at your place of residence.

Please enter a number from 1 to 30.

Income(Required)

Name

Relationship

Age

Gross income (past 6 months)

Income source(s)

Gross income is the total earnings before taxes and other deductions are subtracted.

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

Annualized family income(Required)

Who is your case manager?(Required)

Release of Information

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.

Please type your full name to agree(Required)

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.

Please type your full name to agree (Optional)

Certification

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. I agree to receive informational emails and text messages from Golden Sierra related to my participation.

Please type your full name to agree(Required)

Comments

This field is for validation purposes and should be left unchanged.

Contact Information

Alternate Contact

Demographic Data

Veteran Information

Employment

Education

Public Assistance

Barriers to Employment

Financial

Confidential Health/Medical Information

Release of Information

Media Release

Certification