Located at 2450 Blake Street in the unincorporated section of San Bernardino (Muscoy) the facility contains basketball, tennis, handball courts, and an adjacent baseball field.

1.
Name SSN Date
2.
Residence Street Address Apt#
3.
Residence City Zip Code Phone
4.
Mailing Address Apt#
5.
Mailing City Zip Code Phone
6.
Citizenship(check one) U.S. Citizen Documented Alien Alien Registration #
7.
Gender Male Female Date of Birth Age
8.
Selective Service Status (for males born on or after 1/1/60) Registered Registration #
 
During The WIA Program, Selective service registration will need to be completed thirty (30) days prior to your eighteenth birthday. Thirty (30) days prior to eighteenth (18th) birthday is
9.
Are you homeless ? Yes No
10.
Are you Veteran ? Yes No If Yes, complete the following:
 
Recently Separated Date of Separation
11.
# in Family
12.
# of Dependents under age 18 Family Status(check one)
 
Parent in One Parent Family Parent in Two Parent Family Family Member Non Family member
13.
Do you or your family receive any of the following forms of Public Assistance? Yes No
 
If Yes, check all that apply: Family TANF Family GA Family RCA Family SSI/SSP
  Food Stamps TANF Grant GA Grant RCA Grant
  SSI/SSP Grant CalWORKS GAIN/JOBS Long-term TANF
14.
Family Size / income: List all household members living with you (include yourself). List each member's income and earnings, including wages and salary, income from self-employment, social security benefits, pensions, spousal support, public assistance, child support, or any other source of income, including regular or periodic income.
 
Family Member (Name) Age Relationship Amount of Income Last 6 months Source of Income
15.
Are you a Pell Grant recipient? Yes No Amount $
16.
Are you a dislocated worker? Yes No If Yes, check all that apply:
 
Laid off or Terminated Self-Employed Laid off due to Plant Closure Long-term Unemployed
Displaced Homemaker      
17.
Hourly Wage as a Dislocated Worker: $
18.
Are you disabled or do you have any disabilities? Yes No If Yes, complete the following:
 
Under a doctor's care? Yes No A Vocational Rehabilitation Client? Yes No
Have any limitaions? Yes No Explain:
19.
Ethnicity:  
 
Asian Indian Filipino Japanese samoan Black,not Hispanic White
Cambodian Guamanian Korean Chinese Hispanic Vietnamese
Hawaiian Latin Other Pacific Islander American Indian/ Alaskan Native
20.
Do you speak limited English? Yes No If Yes, Primary Language:
21.
Have you ever been convicted of a crime? Yes No If Yes, was it a
 
Felony Misdemeanor  
22.
Are you currently or have you ever been treated for substance abuse? Yes No
23.
Education:Are you (check one) H.S. Dropout Student H.S. Graduate or GED Post high School
 
What is the highest grade you completed ?
24.
Have you completed any vocational training? Yes No If Yes, What kind of training did you receive?
25.
Are you currently attending school? Yes No If Yes, Fulltime Part-time
 
Type of school: Secondary Alternative Trade/Tech/Vocational Junior/Community College
  4 Year College/ University    
26.
Are you currently employed? Yes No If Yes, are you Fulltime Part-time
 
  On-Call Hourly Wage $:
27.
Have you ever applied for WIA Service? Yes No If Yes, When?
 
Where?
28.
Through this program, what would you like to obtain?
 
LIST YOUR LAST 3 JOBS, STATING WITH THE LAST JOB YOU HELD,
1. Current or most recent employer
  Address City,State,Zip
  Phone Job Title
  Job Duties Wages
  Date Started Date Left
  Reason For leaving
2. Employer
  Address City,State,Zip
  Phone Job Title
  Job Duties Wages
  Date Started Date Left
  Reason For leaving
3. Employer
  Address City,State,Zip
  Phone Job Title
  Job Duties Wages
  Date Started Date Left
  Reason For leaving
 
CERTIFICATION: (READ BEFORE SIGNING)
By signing this document, I am certifying that all the information on the application form is correct to the best of my knowledge, and I acknowledge that such information is subject to verification. I also acknowledge that my failure to provide necessary documents within a reasonable period of time, or falsification of this information, shall be grounds for my termination from the WIA Programs, and that I may be subject to prosecution under the law. I authorize the release of said information by local, state and/or federal agencies to San Bernardino County staff within one year of this date.
Signature of Applicant Signature of Parent/Guardian(if under 18 years of age)
Date    
 
Please indicate your top 3 Vocational Training Classes that you are interested in.
Place choices in number order 1 - First Choice / 2 - Second Choice
CAREER FIELD CLASSES LIST ONE
MEDICAL    
1. C.N.A.*
2. M.A.*
3. Pharmacy Tech*
4. Medical Terminilogy
5. Emergency Medical Tech(EMT)
6. Basic Medical Academics
7. Home Health Aide
8. Front Office Dental Assistant
9. Medical Insurance Billing
*Must pass an assessment test prior to enrollment*
COMPUTERS    
1. Desktop Publishing / Web Page Design
2. Microsoft Office Suite
3. Typing
4. Excel 2007
5. MS Word 2007
6. MS Access 2007
7. Quickbooks
CLERICAL    
1. Typing / Keyboarding
2. Office Skills
3. Business Communications
4. Bookkeeping
5. Accounting Clerk (4 classes)
6. Receptionist Certificate (4 classes)
  Other Vocational Training Career Classes  
1. Accoutning Clerk (4 classes)
2. Security Officer
3. Customer Service Occupations
4. Auto Repair
5. Construction
6. Teacher's Aide - Child Development
7. Culinary Arts
8. Custodial Training I, II, III
9. Welding (Warehouse)
10. Logistics
11. Barber / Pre - Apprentice (9 weeks)
12. Graphics Design Certificate (5 classes)
13. Data Information Clerk (5 classes)
 
Other
 
Do you have reliable transportation Yes No
 
Are you willing to ride the bus to the following locations; Redlands, Colton, Fontana, Ontario Yes No
  NOTE:Availability of Vocational Training Classes Subject to change.
 
Copyright @ 2007 www.palcenter.org