A PROJECT OF THE County of San Diego Health & Human Services Agency

EXCEL Membership Application

This application asks a few questions that will help us help you with your employment needs. The information will also provide data to track the growth of the EXCEL program. By completing this form, we will be able to provide you the opportunity to access career opportunities, job search activities, and skills enhancement. And it will assist us in continuing to fund these services.

Please print.

Today’s Date:  Last Name: First Name: M.I.:
Social Security Number:   Date of Birth:
Home Address:                                                               City:                                  State:        Zip: 
Home Phone: (                  ) Message Phone: (                  ) Email:
Citizenship (check one):  __ U.S. Citizen__ Eligible Non-Citizen (Resident Alien Doc. # ______________________________ Ineligible Non-Citizen Gender (check one):__ Male__ Female
Ethnicity (check one):__ Asian Indian          __ Laotian                      __ White__ Cambodian            __ Samoan__ Chinese                  __ Vietnamese__ Filipino                  __ Other Pacific Islander__ Guamanian            __ Other Asian__ Hawaiian               __ African American__ Japanese                __ Hispanic/Latino__ Korean                  __ American Indian/Alaskan Native    
Please check if you are participating in any of the following programs:__ Native American Program                                             __ Community Service Block Grant Program__ Veterans’ Workforce Investment Programs                  __ HUD Program__ Veterans’ DVOP/LVER                                                __ Other Non-WIA Program__ Trade Adjustment Act                                                   __ Rapid Response__ NAFTA-TAA                                                                __ Rapid Response – Additional Assistance__ Vocational Education                                                    __ TANF__ Vocational Rehabilitation                                              __ Food Stamp Training Program__ Wagner-Peyser                                                               __ Adult Education__ Wtw-Participant                                                             __ Job Corps__ Title V Activities (OAA)                                               __ Farmworker Program
Are you disabled?     __ Yes, Major                                  __ Yes, Substantial                                  __ No Do you have difficulty reading, writing or speaking the English language?  __ Yes        __ No
Please check if any of the following pertain to you: Please check if any of the following pertain to you:
  Y N   Y N
Substance Abuse     Former Foster Care    
Basic Skills Deficient     Parent or Guardian is Incarcerated    
Offender     Raised by Other than Biological Parents    
Pregnant / Parenting Youth     First-Generation High School Graduate    
Youth Needing Additional Assistance     Runaway Youth    
At risk of Dropping Out     Foster Child    
Family History of Chronic Unemployment     Family TANF    
Gang Involved or Affected     Family General Assistance    
Immigrant or Refugee     Family RCA    
Reside in Areas with High Rates of Poverty, Crime and Unemployment     Family SSI    
Have a Substance Abuse or History     Family Food Stamps    
Print Name: Labor Force Status?  __ Yes      __ No
  Weeks Not Employed in Last 26 Weeks: ________
Number of People in Your Family:  ______ Hourly Wage: $________; Hours Per Week:  _____
Number of Dependents Under Age 18:  _____ Referred by WPRS?  __ Yes      __ No
Family Status:__ Parent in One-Parent Family__ Parent in Two-Parent Family__ Other Family Member__ Not a Family Member__ Not Reported Family Income in Past Six Months: $_____________ Dislocated Worker: __ Terminated/Laid Off__ Received Notice of Layoff__ Long Term Unemployed (JTPA transfer)__ Self Employed__ Displaced Homemaker__ Not Applicable
Low Income?  __ Yes      __ No Job Code at Dislocation:
TANF Exhaustee?  __ Yes      __ No Job Title at Dislocation:
Homeless? __ Yes      __ No Employer Number:
Poor Work History?  __ Yes      __ No Employer Address: City:                                        St:         Zip:
Unemployment Insurance Claimant? __ Yes   __ No__Exhausted Unemployment Insurance Claim
Veteran Status?  __ Yes, <= 180 days                           __ Yes, > 180 days                           __ No Employer Phone: (                  )
Disabled Veteran?  __ Yes                                __ Yes, special disabled                                __ No Part Time Employee:    __ Yes   __ NoSeasonal Employee:      __ Yes   __ NoTemporary Employee:   __ Yes   __ No
Recently Separated Veteran?  __ Yes      __ No Current Hourly Wage:  $ _____________
Veteran Separation Date ___________________ Pre-Dislocation Hourly Wage:  $ _____________
Campaign Veteran?  __ Yes, Vietnam-Era                                  __ Yes, Other Veteran                                  __ No  Health Benefits:  __ Yes   __ No
Spouse of Qualifying Veteran? __ Yes      __ No Non Custodial Parents:  __ Yes   __ No
  Eligibility:__ Adult WIA__ Youth (age 19-21)__ Adult Low Income__ Veteran Grant__ Wildfire__ Dislocated Worker__ 5% Window Youth (age 14-18)__ ODEP__ Youth (age 14-18)__ 5% Window Youth (age 19-21)__ Not Eligible
 
Highest Degree Attained: __ HS Diploma__ GED or Equivalent__ Associates Degree__ Bachelors Degree__ Masters Degree__ Doctorate Degree
Education Status (check one):__ Student, High School or less__ Student, Attending Post High School__ Out-of-School, HS Dropout__ Out-of-School, HS Grad, employment difficulty__ Out-of-School, HS Grad, no employment difficulty__ Alternative School  Are all documents received?   __ Yes   __ No
Highest Grade Completed: ________ Interviewer:
Read Grade: Interview Date:
Read Score: Reviewer:
Reading Test: Review Date:
Math Grade: Agency Name:
Math Score: Contract Code: 
Math Test: Is Form Complete?  __ Yes      __ No