YouthBuild Application

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Your Email:

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Contact Information

First Name

Middle Name

Last Name

Date of Birth

mm/dd/yyyy

Email Address

Street Address

City

State

Zip Code

County

Other County

Preferred Phone

Mobile Phone

Home Phone

Work Phone

How did you hear about YouthBuild?

If not listed, please indicate below:

Demographic Information

Gender

Are you Head of Household?

Female Head of Household

Do you consider yourself Hispanic or Latino?

Race

Do you need any special accommodations in order to participate in this program?

Check all that apply. Please check the "Not Applicable" box if you do not need any special accommodations.

Are you authorized to work in the United States?

Do you have a valid form of identification?

Social Security #

What type of identification do you have?

ID Number

What type of Driver's License do you have?

What is your primary method of transportation?

What is your housing status?

Are you registered with a selective service?

Please select "Not Applicable" if this does not apply to you.

Are you over 24?

Are you at risk of becoming homeless?

Youth Questions

Currently or previously in Foster Care?

Are either of your parents incarcerated?

Have you ever been part of the juvenile justice system?

Do you reside in a single-parent household?

Do you receive free or reduced lunch at school?

Did you drop out of high school?

Are you pregnant or parenting?

Do you lack significant work history?

If you have NOT worked for the same employer more than 3 months, please select "Yes"

Household and Family Info

Marital Status

What is your household's annual income?

Please enter your annual household income. Your best estimate will suffice.

How many children 17 years old and under live in your household?

You should include/count yourself in only one of these categories in addition to other household members.

How many young adults 18-24 years old live in your household?

You should include/count yourself in only one of these categories in addition to other household members.

How many adults over the age of 24 years old live in your household?

You should include/count yourself in only one of these categories in addition to other household members.

If interested: We offer financial coaching & help individuals open a checking and/or savings account, who don't currently have a checking / savings account.

Do you have a checking account?

Do you have a savings account?

Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship to You

Emergency Contact Phone

Alternate Contact Name

Alternate Contact Phone

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Visual	Hearing	Speech
Limited Mobility	Not Applicable

Aggravated assault	Assault
Careless/Reckless Driving	Disorderly Conduct
Drug Possession	DWI
Fraud	Robbery
Shoplifting	Theft
Trespassing	Vandalism
Other

Full time (30+ hours per week)	Part time (20 hours or less per week)
Days (8am to 5pm)	Evenings (6pm to 10pm)
Weekdays (Monday-Friday)	Weekends (Saturday & Sunday)

Background	Homelessness	Lack of Support
Learning Disability	Physical Disability	Substance Abuse
Need of Training	Means of Transportation	Need of Child Care
Other	Lack of Education

Any day Mon - Fri	Monday	Tuesday
Wednesday	Thursday	Friday

Anytime 8AM-5PM	Morning 8:00-11:30AM
Midday 11:30-2:00PM	Afternoon 2:00-5:00PM