Society of St. Vincent De Paul of Alameda County

Society of St. Vincent de Paul of Alameda County

SVDP ALAMEDA
Workforce Training Programs
Application Form

675 23rd Street or 2272 San Pablo Avenue, Oakland CA. 94612 | Phone (510) 877 – 9212 |

GENERALAPPLICANT INFORMATION

Applicant Name: Last______First ______Middle ______

Aliases/Nicknames______SSN ______-______-_____ DOB______/_____/______

Contact- Cell # ______Other #______

Email address ______Gender: ______

Age(years)

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 18 – 23

 24 – 34

 35 – 44

 45 – 54

 55 – 65

 66 & older

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Race and/or Ethnicity

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White  Black and/African American

Asian  American Indian and/or Alaskan Native

Two or more of the above

Hispanic/Latino/Spanish Origin Hispanic/Latino/Spanish Origin and one/more of the above

Not Hispanic, Latino or Spanish  Other, describe ______

Origin

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General Applicant Information (cont’d)

Are you a citizen of the United States?  Yes No

If no, are you legally entitled to work in the U.S.?  Yes No

Have you ever served in any of the armed forces?  Yes No If yes, when?______

Have you received services from SVdP Alameda before? Yes No If yes, when?______

Emergency Contact Name: ______Relationship ______

Emergency Contact Phone: ______Email: ______

HOUSING INFORMATION

Household type:I am homeless I have a current Alameda County residential address

If you have a Current Address:______

City: ______County: Alameda State: CA Zip: ______

Mailing Address (if different): ______

City:______County: ______State: ______Zip: ______

I confirm that my ADDRESS is correct: (sign here) ______

Where did you stay last night?

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Emergency Shelter

Halfway House

Homeless/Street (with no current address)

Homeowner (pays mortgage)

Partner’s apt/Home

Relative’s/Friends Home

Rented apt/Home

Residential Treatment Program

Transitional Housing/Public Housing/Section 8

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If you are homeless or your current housing is unstable, please provide details about your current homelessness or living situation; for instance, describehow and when did you become homeless? If you are staying in a residential or temporaryhousing program, when is your move-out date? If you are staying with a friend temporarily, will this be until you are finished with the training program? Do you have any plans for housing afterwards, what are they? ______

______

______

Have you stayed in a temporary shelter/transitional housing facility in the last 5 years?  Yes No

If YES, what is the name of the facility, when did you enter the program and how did you stay there?

Housing Information (cont’d)

Household Size: Total number of persons in the household _____

Household Type:

Single personSingle female parent-kidsSingle male parent-kids

Two/more adults no childrenTwo-parents, kidsOther ______

Number of children in household ______Ages of children  1 – 9 10 – 17 18 & older

Listall the members of your household, that is, all the persons with whom you live, including children:

Name of Person / Relationship / Age

Are any of the children under 18 years in your custody?  Yes No

If YES, what are your plans for stable quality childcare during the program or while in full-time employment?

______

Are you responsible for any other family member (i.e. an aging parent, disabled relative, babysitting a younger family member)? If yes, please describe.

EDUCATIONHISTORY

Describe your education level

 Grades 9 – 12, did not graduate High School Diploma/GED

 Courses after completing High School  Vocational Skills Training and/or Certification

 2 or 4 year College Graduate Post 1st degree or graduate studies

Describe any other Certificates or Diplomas received:

Do you speak/write any other language(s) beside English?

INCOME INFORMATION

My total monthly income: ______Total household monthly income: ______
(Write ‘0’ if there is no income)

Are any of these your source(s) of income or do you have a pending application for any of them? Check all that apply.

 SSI/SSDI Social Security General Assistance

 TANF Food Stamps  Unemployment Insurance

 Pension Child Support Veteran’s Benefits

 Job Wages onlyWages + other sourcesother ______

Have you ever applied for?

 SSI  SSDI  IDANONEof these

If YES, when? ____/____/_____ Application status, including any appeals

I confirm that my INCOME information is correct. (Sign here)

HEALTH INFORMATION

Do you have a disability that substantially limits your major life activities?  Yes No

Please describe your disability? (For example Physical Disability; Mental Illness, Substance use related,

Developmental/Learning Disability)

When was your last TB/PPD test? _____/____/_____ What was the result? Negative Positive

If your TB test was positive, provide a medical report of the prescribed treatment plan.  Yes No

List any allergies orsensitivity issues that you may have (for instance can’t touch, eat or work with certain types of foods, liquids, chemicals or materials)

Do you take prescription medications foror do you see a medical doctor for any of the followingor any other conditions?

Hypertension High Blood Pressure Post Traumatic Stress Disorder

High Cholesterol Bi-Polar Disorder  Mental or emotional Disorder

Schizophrenia  Diabetes Other______

If you take medication or are currently under a doctor’s care, provide your health provider/doctor’s contact:

______ Name of Doctor Address Phone Number

If you currently take medication provide a list of the medication

Medication and related Condition / Dosage / Prescribing Doctor / Date started

Health Information(cont’d)

Are you currently on any medication that causes drowsiness or any side effects that may be dangerous to your performance and safety during job training?  Yes  No

If yes, explain side effects

Have you ever had any of the following or any other food-borne illnesses?

 E-coli  Hepatitis A virus Salmonella Other

SUBSTANCE HISTORY

Do you currently use any alcohol or drugs?  Yes No

Have you used or taken any type of alcohol or drugs in the last 6 months?  Yes No

Please list all types of alcohol or drugs you have taken in the past of are currently taking below:

Type of drug / How often used / How much used / Date you used last

Have you ever been in a drug or alcohol treatment program  Yes  No

If yes, please when and where list below:

Program Name / Inpatient or Outpatient or Residential / Dates of Participation / Program
Completed?

In the last 5 years, what is the longest period you have abstained from drugs and alcohol use?

If you have used alcohol and drugs in the past and are now sober, how long have you been clean and sober? How do you maintain your sobriety?

EMPLOYMENTHISTORY

Have you ever worked?  Yes  No

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If yes, when did you end was your last Job? ______

How long did you work at your last position? ______

Do you have any experience in the job field for which you are applying?  Yes  No

Do you have a resume?

 I have a current resume My resume needs to be updatedI do not have a resume

Employment History (cont’d)

List your 2 most recent work experiences below. Start with your most recent job held. If you were self-employed, please say so.

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______

Job 1 (Name of Employer)

______

Address

______

City, State, Zip

______

Telephone Number

______
Email Address

______

Job Title

______

Starting Pay

______

Ending Pay

______

Main Duties

______
Main Duties

______

Supervisor’s Name

______

Reason for Leaving

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______

Job 2 (Name of Employer)

______

Address

______

City, State, Zip

______

Telephone Number

______
Email Address

______

Job Title

______

Starting Pay

______

Ending Pay

______

Main Duties

______
Main Duties

______

Supervisor’s Name

______

Reason for Leaving

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LEGAL HISTORY

Do you have any warrants, upcoming court dates or pending legal matters?  Yes No

If YES, please explain______

______

Have you ever been arrested, placed in custody? Yes NoIf yes, When? ______

Have you ever been convicted of a misdemeanor?  Yes  No If yes, When? ______

What was the charge/s? ______

Have you ever been convicted of a felony?  Yes No If yes, When? ______

What was the charge/s? ______

Have you ever served time in prison or jail? Yes No

If yes, when(for example 2001-2006) ______

What were the convictions?______

Are you currently on?  Probation Parole  Work release

Until when? ______Agent/Officer name: ______

How often do you report? ______Agent/Officer phone: ______

End
APPLICANT PROFILE

What are some of your personal strengths?

______

______

______

What are some of the main challenges in your life currently? What help do you need to deal with them?

______

______

______

What makes you a good fit for this training program?

______

______

______

What are your employment goals? Are you committed to gaining employment at the end of the training program? ______

______

What are some of the other goals you would like toachieve during your time in the program? ______

______

______

How do you deal with stressful situations? Describe the strategy you would use if you were tobecome angry, frustrated, and overwhelmed. How would you handle an argument with someone else?

______

______

______

Do you have a support group or network? Describe your support.

______

______

______

Does anyone in your household use drugs or alcohol daily or frequently? Yes No

Does anyone in your household displayphysically or verbally threatening behavior? Yes No

SVDP ALAMEDA Workforce Training Programs

Listed below are some of the SVdP Workforce Training Programs requirements that participants are expected to meet.

Please initial after each one to indicate that you understand and agree to the agreement.

I understand that daily attendance is required. ______

I understand that I must be on time and prepared to stay the entire day. ______

I understand that I must be willing to accept instruction from my instructors and supervisors and complete the work that is assigned to me with a positive attitude. ______

I understand that I must have a willingness to confront my personal challenges and/or barriers. _____

I understand that I must be clean and sober during training. ______

I understand that SVDP is not responsible for damage, loss or theft of my personal property. ______

I understand that allI must attend all training sessions and activities that are relevant to my program. ______

I understand that the Champion Workforce and the Kitchen of Champion programs are temporary and are

notoffered as a permanent position with the Society of St. Vincent de Paul of Alameda County.______

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Society of St. Vincent de Paul of Alameda County permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Society of St. Vincent de Paul of Alameda County from any liability as a result of such contact.
I also understand that:
(1) the Society of St. Vincent de Paul of Alameda County has a drug and alcohol policy that provides for random and causal testing before and/or during the program;
(2) I consent to and am in compliance with such policy at the time of my enrollment;
(3) My continued enrollment is based on the successful passing of testing under such policy;
(4) I further understand that continued enrollment may be based on the successful passing of job-related physical examinations.

Applicant’s Signature: ______Date: _____/____/_____

SVDP ALAMEDA

RELEASE AND WAIVER OF LIABILITY

This Release and Waiver of Liability is executed on this day by the signer below in favor of the Society of St. Vincent de Paul of Alameda County, a non-profit organization, its directors, officers, employees and agents. The signer desires to be workforce training program participant of the Society of St. Vincent de Paul of Alameda County and engage in the activities related to being a trainee or transitional employment.

The participant does hereby freely, voluntarily and without duress execute this release under the following terms:

1.Waiver and Release – Participant does hereby release and forever discharge and hold harmless the Society of St. Vincent de Paul and its successors and assigns from it any and all liability, claims and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the participant’s work for the Society of St. Vincent de Paul of Alameda County. The participant understands that this release discharges the Society of St. Vincent de Paul from any liability or claim that the participant may have against the Society of St. Vincent de Paul of Alameda County with respect to any bodily injury, personal injury, death or property damage that may result from participant work for the Society of St. Vincent de Paul of Alameda County whether caused by the negligence of the Society of St. Vincent de Paul of Alameda County, or its officers, directors, employees, agents, or otherwise. The participant also understands that the Society of St. Vincent de Paul of Alameda County does not assume any responsibility for or obligation to provide financial assistance or other assistance including, but not limited to, medical, health, or disability insurance in the event of injury or illness.

2.Medical Treatment – Except as otherwise agreed to by the Society of St. Vincent de Paul of Alameda County in writing, the participant does hereby release and forever discharge the Society of St. Vincent de Paul of Alameda County from any claim whatsoever that arises or any hereafter arise on account of any first aid, treatment, or service rendered in connection with the participant’s work with the Society of St. Vincent de Paul of Alameda County.

3.Assumption of Risk – The participant expressly and specifically assumes the risk of injury or harm in these activities and releases the Society of St. Vincent de Paul of Alameda County from all liability for injury, illness, death, or property damage resulting from the activities of the participant’s work for the Society of St. Vincent de Paul of Alameda County.

4.Insurance – The participant understands that, except as otherwise agreed to by the Society of St. Vincent de Paul of Alameda County in writing; the Society of St. Vincent de Paul of Alameda County does not carry or maintain health, medical, or disability insurance coverage for any participant. The participant is expected, and encouraged to obtain his or her own medical or health insurance coverage.

5.Photographic Release – The participantdoes hereby grant and convey unto the Society of St. Vincent de Paul of Alameda County all right, title and interest in any and all photographic images and video or audio recordings made by the Society of St. Vincent de Paul of Alameda County during the participant’s work for the Society of St. Vincent de Paul of Alameda County including, but not limited to, any royalties, proceeds or other benefits derived from such photographs or recordings.

6.Other – The participantexpressly agrees that this release is intended to be as broad and inclusive as permitted by the laws of the State of California and that this release shall be governed by and interpreted in accordance with the laws of the State of California. The participant agrees that in the event that any clause or provision of the Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this release which shall continue to be enforceable.

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Applicant SignatureWorkforce Training Programs Staff’s Signature

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DateDate

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