WORKFORCE Transitions APPLICATION

WORKFORCE Transitions APPLICATION

Applicant Information

Name:______
Preferred Name:______ / Date:
Date of Birth: / SSN: / SID:
Street Address:
City / Zip: / Phone: / Alt Phone:
Email: (print clearly) / Are you a Washington resident? (Living in WA 1 or more years)
 Yes  No
Total Household Size: ______ / # of Adults ______/ # of Children ______
# of children: 0-5 years ______/ 6-12 years ______/ 13-18 years ______

Education Information

Program of Study:______
Program Start Date:______ /  AAS  Certificate  Other______
Projected End Date:______ / Will you be attending:
 Full-time (12+ credits)
 3/4 time (9-11 credits)
 Part-time (6-8 credits)
Do you have a high school diploma or GED?
 Yes  No / Currently enrolled in classes at SPSCC?
 Yes  No
What is your highest level of education?
 Less than HS  Certificate of Completion  Bachelor’s Degree
 HS Diploma or GED  Associates Degree  Post Bachelor’s Degree
If you do not have a degree, how many college credits have you earned?
 NONE  1-30  31-90  91 or more
List all colleges you have attended:______
______
Have you ever completed an educational plan with an SPSCC advisor?  Yes  No
Have you previously or are you currently receiving these services from any school or provider?
 Basic Food Employment and Training  Worker Retraining  WorkFirst  Opportunity Grant
What program(s) are you applying for today? Check one or more:
 Opportunity Grant /  BFET
 WorkFirst /  Worker Retraining
 Signed Scan Staff use only

financial information

Total family income per month (include spouse or parents if applicable): $______
Currently receiving TANF?
 Yes  No  Former TANF / On Social Security?
 Yes  No / Collecting Veteran’s Benefits?
 Yes  No
Currently receiving
Basic Food (stamps)?
 Yes  No / Have you applied for Financial Aid (FAFSA)?
 Yes  No If so, when?___ / Receiving other forms of Financial Aid? (Scholarships, WIA, Trade Act, Loans, etc.)  Yes  No
Yes No
  Are you currently receiving Unemployment?
  Are you eligible for Unemployment?
  Have you exhausted Unemployment benefits within the past 48 months?
  Currently working but have received written notice of layoff or collecting Unemployment?
  Displaced homemaker within past 48 months?
  Were you self-employed but now unemployed due to economic factors?
  Military Veteran honorably discharged within past 48 months?
  Are you currently employed?

Employment HISTORY

Beginning with the most recent, provide the past five years of employment history. Attach another page if needed.
Employer Name: ______
City, State: ______
Start Date: ______ / Position Title: ______
Hours per Week:______
End Date: ______
Employer Name: ______
City, State: ______
Start Date: ______ / Position Title: ______
Hours per Week: ______
End Date: ______
Employer Name: ______
City, State: ______
Start Date: ______ / Position Title: ______
Hours per Week: ______
End Date: ______
Employer Name: ______
City, State: ______
Start Date: ______ / Position Title: ______
Hours per Week: ______
End Date: ______

DSHS Release of Information

“I,______, give permission for the Washington State Department of Social and Health Services and South Puget Sound Community College to use and share confidential information about me (except as limited below) as necessary for Employment and Training (E&T) activities as required by the Basic Food E&T (BFET) program. This consent is valid for a maximum of three years from the date signed, unless I withdraw or change my consent in writing. This consent DOES NOT permit sharing of sensitive information about my mental health, chemical dependency, HIV/AIDS and STD test results, diagnosis or treatment. I understand that I must fill out a separately approved consent form if I am under 18 years of age, I want to further limit information shared about me, someone else is representing me in this matter, or I want to allow sharing of sensitive information about my mental health, chemical dependency, HIV/AIDS and STD test results, diagnosis or treatment.”
Signature of applicant: / Date:

Z:\Workforce Department\WFD App and Ed Plan\ \WFD Grant Application 7-1-14(updated 7-1-14 MEB)

WORKFORCe Transitions employment & EDUCATION plan

Name: / Student ID: / Date:
Please describe your career goals including
short-term (0-2 years)______
______
long-term (2+ years)______
______
Why did you choose this career path? What led to the decision to choose this career?
Please list some of your strengths, skills, abilities and/or interests that relate to this career path and will help you reach your career goals.
1. / 4.
2. / 5.
3. / 6.
What have your previous experiences in school been like? (check all that apply)
 Rewarding
 Fun
 Exciting
 Easy /  Encouraging
 Challenging
 Difficult /  Frustrating
 Discouraging Other______
What are some potential obstacles and challenges that you may encounter in pursuing your career and educational goals? (check all that apply)
 Time for school / work / family
 Academics/Grades
 Computer Skills
 Computer/Internet Access
 Disability /  Reliable Transportation
 Finances (including educational costs)
 Housing
 Dependable Childcare /  Family / Friend Support
 Health
 Legal Issues
 Stable Living Situation
Other______
What steps will you need to take in order to successfully reach your career goals and overcome obstacles?
______
______
Advisor Support-Work with your advisor to develop additional steps:
______
______

Z:\Workforce Department\WFD App and Ed Plan\ \WFD Grant Application 7-1-14(updated 7-1-14 MEB)