Applicant Information
LAST NAMEMIDDLE INITIALFIRST NAME ALIASES/MAIDEN NAME
CITYSTREET ADDRESS STATE ZIP CODE
MALE FEMALE
SEX BIRTH DATE AGE SOCIAL SECURITY NUMBER
ALTERNATE PHONEMOBILE PHONE EMAIL
YES NO
ARE YOU A VETERAN? RACE/ETHNICITY
RELATIONSHIPEMERGENCY CONTACT PHONE
Basic Eligibility
YES NO
ARE YOU A U.S. CITIZEN? PLACE OF BIRTH
EXPIRATION DATEIF NOT, PERMANENT RESIDENT CARD NUMBER LANGUAGES SPOKEN
YES NO
$
DO YOU RECEIVE TANF CASH BENEFITS? IF YES, HOW LONG? TANF GRANT PER MONTH
YES NO
COMMUNITY SERVICE OFFICE DO YOU RECEIVE BASIC FOOD (FOOD STAMPS)?
Income Eligibility
To be eligible for PSH, family taxable income cannot exceed 70 percent of the Lower Living Standard Income Level based on the preceding year. Copies of ofcial
federal tax records for the preceding year may be required for verication.
$
YES NO
MONTHLY FAMILY GROSS INCOME ARE YOU EMPLOYED? IF YES, NAME OF EMPLOYER
$
YES NO YES NO
HOW MANY HOURS PER WEEK? WAGE PER HOUR ARE YOU CURRENTLY RECEIVING UNEMPLOYMENT BENEFITS? HAVE YOU RECEIVED UNEMPLOYMENT BENEFITS IN THE LAST 24 MONTHS?
TRIO GRANT WORKFORCE INVESTMENT ACT IN SCHOOL/OUT SCHOOL WIB
LIST OTHER SOURCES OF INCOME? (E.G., CHILD SUPPORT, SSDI, ETC.) ARE YOU ENROLLED IN ANY OF THESE PROGRAMS? CHECK ALL THAT APPLY.
Background Checks
As required to apply for Nursing Assistant Certication in Pennsylvania and as a condition of employment in health care, PSH conducts an in-depth criminal
background check on each applicant. For additional information about state requirements, visit https://www.ccac.edu/Nurse_Aide_Training_Program.aspx.
YES NO
HAVE YOU EVER BEEN CONVICTED, ENTERED A PLEA OF GUILTY, NO CONTEST OR A SIMILAR PLEA, OR HAD PROSECUTION OR A SENTENCE DEFERRED OR SUSPENDED AS AN ADULT OR JUVENILE IN ANY STATE OR JURISDICTION?
IF YES, PLEASE EXPLAIN.
YES NO
ARE YOU NOW SUBJECT TO CRIMINAL PROSECUTION OR PENDING CHARGES OF A CRIME IN ANY STATE OR JURISDICTION?
IF YES, PLEASE EXPLAIN.
YES NO
OTHER THAN ANY MATTER ABOVE, IS THERE ANY FACT OR CIRCUMSTANCE INVOLVING YOU AND YOUR BACKGROUND THAT WOULD CALL INTO QUESTION YOU BEING ENTRUSTED WITH THE CARE, GUIDANCE OR SUPERVISION
OF VULNERABLE ADULTS, YOUNG PEOPLE OR DEVELOPMENTALLY DISABLED PERSONS?
IF YES, PLEASE EXPLAIN.
Personal & Family Needs & Support Systems
SINGLE MARRIED SEPARATED DIVORCED
NUMBER OF PEOPLE IN HOUSEHOLDMARITAL STATUS NUMBER OF CHILDREN UNDER AGE 18 IN YOUR FAMILY AGES OF YOUR CHILDREN
IF YOU HAVE CHILDREN OF CHILD CARE AGE, WHAT IS YOUR PLAN FOR THEM WHILE YOU ARE IN PSH? DO YOU ALREADY HAVE CHILD CARE IN PLACE, OR WILL YOU NEED ASSISTANCE IN SECURING CHILD CARE? PLEASE DESCRIBE.
CAR BUS OTHER YES NO YES NO
HOW DO YOU PLAN TO TRAVEL TO CLASS? IS TRANSPORTATION A PROBLEM? IF YES, WILL YOU NEED ASSISTANCE WITH TRANSPORTATION?
HPOG is a study funded by the federal government which is being conducted to determine how these training opportunities help people improve their skills and
nd better jobs. During the study, all new eligible applicants will be selected by lottery to participate in these training opportunities. Not all eligible applicants will
be selected to participate in these opportunities.
