Pre-Application Form
Instructions:
Are you eligible for the program? Click here to find out and fill out the Barrier Form.
Then fill out the Pre-application below and then print and fill out the Participant Questionnaire . You must bring your Participant Questionnaire and Barrier Form with you to your program interview.
WIA Youth Program Pre-Application

Answer ALL questions- Information is confidential. Filling out this application takes approximately 15 minutes. This pre-application is also available as a hard copy on the WIA resources page.

Every field must be filled out. If the field does not apply to you, please indicate n/a for not applicable. You must be a California resident in the County of San Bernardino to apply.

If you are 18-21 years old, you will be applying as a family of one and will not need to include any information about family income (refer to all fields required in section #22. Please place N/A in each field in this section)
Applicant Information
1. First & Last Name: *
2. Date: *
3. Residence Address:
(street, city, state,  zip)
*
4. Phone: *
5.Citizenship (check one):
6. Documented Alien Registration # (if applicable): *
7. Gender:
8. Date of Birth: * (mm/dd/yy)
9. Are you homeless?:
10. # of Dependents under the age of 18 *
11. Family Status (check one):
12. Do you or your family receive any of the following forms of Public Assistance?:
13. 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 info:
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 (first and last name): *
Age: *
Relationship: *
Amount of Income- Last 6 months: *
Source of Income: *
Family Member (first and last name): *
Age: *
Relationship: *
Amount of Income- Last 6 months: *
Source of Income: *
Family Member (first and last name): *
Age: *
Relationship: *
Amount of Income- Last 6 months: *
Source of Income: *
Family Member (first and last name): *
Age:: *
Relationship: *
Amount of Income- Last 6 months: *
Source of Income: *
Family Member (first and last name): *
Age: *
Relationship: *
Amount of Income- Last 6 months: *
Source of Income: *
15. Are you disabled or do you have any disabilities?:
16. Ethnicity- select that apply:
 Asian Indian
  Filipino
  Japanese
  Samoan
  Black, not Hispanic
  White
  Cambodian
  Guamanian
  Korean
  Chinese
  Hispanic
  Vietnamese
  Hawaiian
  Laotian
  Other Pacific Island
  American Indian/ Alaskan Native
17. Have you even been convicted of a crime?:
18. If YES, please indicate Felony or Misdemeanor: *
19. Education- select one:
20. Are you currently attending school?:
21. Have you ever applied for WIA Service?:
22. What are your top three choices for the Certification Programs offered? Please list in order in the space provided: *
23. How did you hear about our program at Career Institute?: *
24. Through this program, what would you like to obtain?: *
25. Certification: (READ BEFORE SIGNING)
By signing (electronically) 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 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.
Date: *
Electronic Signature: *
Signature of Parent/Guardian (if under 18 years of age): *
Email Address: *

 
Don't forget to fill out the Participant Questionnaire and give yourself time to fill it out thoroughly. 

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