Youth Employment Program Eligibility Application

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Youth First Name

Youth Last Name

Social Security Number

###-###-####

Email Address

Phone Number

Alternative Phone Number

Date of Birth

MM/DD/YYYY

Gender at birth

MaleFemalePrefer not to answer

Emergency Contact

Relationship

Emergency Contact Phone Number

Mailing Address

Street Address

City

State

Zipcode

Residential Address

Street Address

City

State

Zipcode

Race

Black/African AmericanAmerican Indian/Alaska NativeWhite/CaucasianHawaiian Islander/Other Pacific IslanderAsianOther

Other, please specify

Ethnicity

LatinoNot LatinoPrefer not to answer

Have you participated in a work experience/readiness program?

NoYes

If yes, please provide dates of participation and program provider:

Citizenship

US CitizenshipRegistered AlienRefugeeOther Legal AlienOther

Please specify:

Attending School?

YesNo

School Name:

Last Grade Completed:

Additional Eligibility

Do you have additional barriers to securing and/or maintaining employment? Please check all that apply.

Explain:

Acknowledgement

By signing, I attest that the information stated on this application is true and accurate. I understand that if the information or income provided was misrepresented, it may be grounds for immediate termination in the Youth Employment program. If the applicant is under age 18, the parent/guardian signature below gives permission for the youth to participate in the Youth Employment Program services and activities.

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Contact Information