Year Round Youth

Contact Information

Email Address *

First Name *

Last Name *

Which career center is closest to your home?

Date of Birth:

Age *

Education Status *

Telephone Number *

Alternate Telephone Number

Are you able to to attend a 5 week course, Monday to Friday from 9am to 3pm?

Do you have reliable transportation?

Will you be able to attend class and be dressed for job interview every day?

Are you currently working?

Working

Referred by

INDIVIDUAL BARRIERS

Are you an individual with limited English or difficulties with reading, writing or understanding English? Do you consider yourself to have a disability? Are you a pregnant or parenting youth? Are you a high school drop out? Are you homeless? Are you a runaway? Are you a foster care youth? Are you an offender?

PUBLIC ASSISTANCE

Are you or your parent/guardian receiving Temporary Assistance for Needy Families? (TANF) Are you receiving Supplemental Security Income? (SSI)
Are you receiving Social Security Disability Income? (SSD) Are you in a household receiving food stamps?

INCOME INFORMATION

What is your family size? What is your annual family income? $