SCSEP Individual Participant Intake Form

SCSEP individual participant intake form

Thank you for interested in our Senior Community Service Employment Program (SCSEP), please fill out the form below and our staff will contact you to confirm and take you to further step
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
do you live in Harris County or Fort Bend County?
Are you 55 years old or older today?
Are you currently unemployed?
Are you able to attend our information session, held on the 1st or 3rd Thursday of the month?

Other
Other:
What should you bring to the information session?

Other
Other:
Would you be interested in receiving training?
What language do you prefer for our staff to contact you?

Other
Other:
Please verify that you are human
Should be Empty:

SCSEP individual participant intake form