Program Eligibility Requirements Program Eligibility Requirements To be considered for enrollment in Felton Institute’s SCSEP program, please confirm that you meet the following eligibility requirements: I am 55 years of age or older I am currently unemployed I am currently looking for work I am legally able to work in the U.S. I am a Bay Area resident and live in Marin, San Francisco, or San Mateo County I meet the low-income financial eligibility requirements

Select your Bay Area County Our program serves San Francisco, Marin and San Mateo County. Felton SCSEP participants must be a resident of one of those counties. Choose...San Mateo CountyThe City and County of San FranciscoMarin County

First Name

Last Name

Date of Birth

Street Address

City

Zipcode

Email

Phone Number

Highest Level of Education Select...Some High SchoolHigh School DiplomaGED or Certificate of Equivalency for High SchoolVocational/Technical Certificate or Degree2-year Associates DegreeSome College4-year Bachelors DegreeEducation beyond a bachelor’s degreeMaster’s DegreeDoctoral Degree

What best describes your gender? Select...FemaleMaleTransgenderNon-binary/non-conformingPrefer not to sayOther/Prefer to self-describe

Gender: Other/Prefer to self-describe

What is your race or ethnicity? What is your race or ethnicity? Select all that apply. American Indian or Alaska Native Asian Black or African American Hispanic or Latino Multiracial/Two or More Races Middle Eastern or North African Native Hawaiian or Other Pacific Islander White Race and Ethnicity unknown Decline to self-identify

Do you have Limited English Proficiency (LEP)? Do you have Limited English Proficiency (LEP)? Yes No

If LEP, please specify primary language

How long have you been looking for employment?

Reason for Leaving Your Last Job Position

Marital Status SingleMarriedWidowedDivorced

Do you have any dependents? Do you have any dependents? Yes No

If so, how many dependents?

Number of Adults Living at Residence?

Current sources of income, support and public assistance received in the last 6 - 12 months. Current sources of income, support and public assistance received in the last 6 - 12 months. Please check all that apply Self-Employment/Odd Jobs Earnings (wages, salary) from an Employer Social Security Retirement SSDI benefits (Social Security Disability Insurance) including short-term & long-term SSI (Supplemental Security Income) Pension or Retirement Income Survivors benefit Unemployment Benefits CalFresh / Food Stamps California CalWORKs (TANF) State or local welfare (General Assistance) Subsidized Housing VA Disability / Retirement Workers Compensation Rental Income Annuities Child Support Financial Help From Others Other Sources of Monthly Income:

Other Sources of Monthly Income:

What is your estimated total annual family income?

Do you have a limit on the amount of money that you can make at a job? Do you have a limit on the amount of money that you can make at a job? Yes No Unsure

If so, what is the limit?

Barriers to Employment Barriers to Employment Please check all that apply Poor Computer/Keyboarding Skills Lack of Office Experience Lack of Transportation No GED/Diploma Low Self-Esteem Ex-Offender (Convicted or pled guilty to a crime excluding traffic violations) Live in county of persistent unemployment Other:

Other Barriers to Employment:

Are you looking for Full-Time or Part-Time work? Are you looking for Full-Time or Part-Time work? Full-Time Part-Time

Type of Training Site Desired Type of Training Site Desired Please check all that apply Administrative Building Maintenance Worker Case Management Childcare Provider Customer Service Representative Data Entry Education/After School Care/Teachers’ aide Food Preparation & Serving Grounds Keeping Healthcare Support (e.g. CNA, Patient Tech) Janitorial Personal Care & Service Other, please describe

Other Training Site Interests: Please note that training placements are based on position availability and current community partnership.

What Type of Employment Are You Seeking?

What type of transportation do you have access to? What type of transportation do you have access to? Own Car Other's Car Bus/Muni/BART/Public Transportation Other

Other type of transportation:

How far are you willing to travel for training or work?

Have you participated in a SCSEP program before? Have you participated in a SCSEP program before? Yes No

How did you find out about our SCSEP program? How did you find out about our SCSEP program? Career Center Case manager/case worker/social worker Current or past SCSEP participant Department of Labor referral Facebook ad Felton Institute website Flyer/brochure/poster in the community A friend/family/neighbor. Word of Mouth Google Search I was enrolled in SCSEP previously Instagram ad Job fair/business expo Job fair/business expo Local government agency referral Newspaper ad Nextdoor.com ad Printed Postcard Mailer Radio or TV broadcast Other:

How did you find out about Felton SCSEP?

Do you have any questions for us?

Upload Your Resume You can also send us your resume via email to SCSEP@felton.org. File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, js, xcf, mpp, docx, numbers. Max. file size: 1 MB

New Field New Field I certify that the information that I have provided on this document is accurate to best of my knowledge. I am aware that the information I have provided is subject to review and verification.

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