Pinellas County Urban League - Client Profile Form

How may we help you?

Select one or more programs that you are interested in.

Anchor in Job Training, Placement & Entrepreneurship Urban Seniors Jobs Program (USJP)- Seniors 55+ or older in Pasco, Hernando, Marion, Seminole, Lake and Sumter counties ONLY. Are you a senior looking to re-enter the job market or thinking about a second career? Do you need training to increase your skills? USJP may be a fit for you! We offer paid training opportunities for seniors 55+.

Workforce / Jobs Training – Get access to career counseling, job coaching, employability skills training, and job referral; help with resume and completion of applications.

Successful Training and Empowerment Project (STEP)- STEP is a transformational Program for families living in St. Petersburg who desire to Improve their quality of life. In addition you will receive mentoring and counseling toward goal setting, life skills, career and personal development training.

Champion for Education & Community Leadership

GED Program – It’s never too late! Start earning your GED today! Contact Beth Bridges 727-327-2081 ext. 111 Summer Training in Youth Leadership & Employment (STYLE) - An 8-week summer program that provides specific instruction and hands-on training in workplace-related skill-sets such as entrepreneurship, finances, team building, problem-solving, critical thinking, effective business communications, professional appearance, and professional demeanor.

STYLE serves 50 youth ages 14-16 that reside in the City of St. Petersburg and meet income guidelines.

Leader in Health Impact & Quality of Life

Affordable Care Act Navigator Program

Do you need health insurance? With newly expanded financial assistance, 4 out of 5 people will be able to find plans for $10/month or less. You can meet with a Pinellas County Urban League Navigator that will help you get covered through the healthcare marketplace, including Medicaid and other health plans.

Community Health Navigators
Need more information on the Covid-19 vaccine? Are you or anyone you know at high risk for Covid complications? Is it time for your booster? Need access to community health resources? Just want more information to make an informed decision? We have knowledge navigators that can help you with your options.

Hub of Housing & Community Development

Weatherization Assistance Program – If your energy bill is too expensive, your home may qualify for measures to help reduce energy costs.

NEXT STEPS: Affordable Care Navigator will be sent to your email

Thank you for completing Part 1. Please check your email for next steps for this application. A copy of this link will be sent to your email address.

Youth Empowerment Programs Assessment Page 1

Youth and Family Services is a robust all-inclusive set of programs and initiatives that assist youth and their families. The following serves as your general assessment for consideration into all such applicable programs and initiatives including STYLE and YEP.

Youth Empowerment Programs

1 (age 10 - 18)2 (age 16 - 24)

Participant Name:

Address

City

State

Zip

Contact Information

Cellphone

Email Address

Sex

MaleFemale

Ethnicity

Date of Birth

Education

Name of School

Grade

GPA

Youth Empowerment Programs Assessment Page 2

Emergency Contact

Emergency Contact Name

Relationship to Participant

Contact Number

Parent/Guardian Information

Parent/Guardian Name

Address

City

State

Zip

Email Address

Phone

Youth Empowerment Programs Assessment Page 4

Medical Consent

CHECK THE OPTION THAT BEST MEETS THE MEDICAL RESPONSE FOR YOU AND/OR THE PARTICIPANT. INITIAL WHERE INSTRUCTED:

IF DURING THE NULITES PROGRAM THE PARTICIPANT (MYSELF OR MY CHILD), IN THE OPINION OF THE YOUTH ADVISORS/OFFICIALS IS IN NEED OF EMERGENCY MEDICAL/HOSPITAL CONSULTATION OR TREATMENT, I HEREBY:

I AUTHORIZE CONSULTATIONS OR MEDICAL TREATMENT AS DEEMED NECESSARY WITHOUT NOTIFICATION TO MY EMERGENCY CONTACT PERSON IF SAID INJURY IS DEEMED LIFE THREATENING OR LOSS OF LIMB AND/OR EXTREMITY IS INVOLVED.IN CASE OF ALL MEDICAL EMERGENCIES, MY EMERGENCY CONTACT SHOULD BE NOTIFIED BEFORE TREATMENT IS ADMINISTERED.DUE TO RELIGIOUS OR PERSONAL BELIEFS, I DO NOT AUTHORIZE CONSULTATIONS OR MEDICAL TREATMENT.

I UNDERSTAND AS THE PARENT/GUARDIAN OF THE PARTICIPANT, THAT I AM FULLY RESPONSIBLE FOR ENSURING THAT THE PARTICIPANT BRINGS SUFFICIENT AMOUNT OF ALL MEDICATIONS, PRESCRIPTIONS, SUPPLIES AND DEVICES REQUIRED FOR HIS/HER PROFESSIONALLY PRESCRIBED MEDICAL CARE, TO COVER THE FULL DURATION OF ALL ACTIVITIES.

PARTICIPANT, PARENT, AND OR LEGAL GUARDIAN INITIAL HERE:

I UNDERSTAND AS THE PARENT/GUARDIAN OF THE PARTICIPANT, THAT THE PARTICIPANT IS FULLY RESPONSIBLE FOR THE APPROPRIATE, TIMELY, CONSISTENT AND COMPLETE ADMINISTRATION OF ALL HIS/HER EXISTING, PROFESSIONALLY PRESCRIBED MEDICAL CARE, INCLUDING ROUTINE MEDICATIONS, ANTIBIOTICS, AND ORTHOTIC DEVICES AND WOUND CARE.

PARTICIPANT, PARENT, AND OR LEGAL GUARDIAN INITIAL HERE:

PARTICIPANT SIGNATURE

Date

PARENT/GUARDIAN SIGNATURE

Date

a. Limited Liability Corporation (LLC)	b. Sole Proprietorship	c. Partnership
d. Corporation	e. To be Determined	'f. DBA (Doing Business As)

Transportation	Housing/Homelessness	Criminal Record
Family Issues	Mental Health	Substance Abuse/Alcohol
Other	None

Own Vehicle	Bicycle
Public Transportation	Walk
Use a Vehicle	Friends/Family

Recently had a baby (natural, foster care, or adoption)	Recently married, divorced or separated
Recently moved	Recently released from incarceration
Recently lost health coverage	Recently homeless or in transitional housing