YouthBuild ApplicationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Birthday*Age*EthnicityEmail Household members living with you at the above address:*First and Last name, Relationship, Age of household membersWhere did you hear about YouthBuild? Court System Probation Office Truancy Office High School Counselor Past Participant Social Media OtherWhy are you interested in being in this program?What is your dream job?If you are accepted into this program, you will be expected to spend 12 hours/ week in an academic setting with emphasis placed on reading, writing, math and construction as well as GED preparation. The remaining 12 hours will be spent at work sites where housing rehab/construction will take place. Programs hours are: Monday through Friday, 8:15 am to 4:00 pm.HealthDo you have any physical, medical, or health problems? Yes NoIf yes, please describe:Do you wear eyeglasses Yes NoDo you have asthma? Yes NoDo you have Diabetes? Yes NoDo you smoke? Yes NoIf you smoke, can you limit your smoking to breaks and lunchtime? Yes NoHave you ever had a physical examination? Yes NoIf yes, when was your last physical exam date?EducationDid you have an IEP? Yes NoIf yes, what accommodations were made for you?If you did not complete high school or get your GED, why did you drop out?Did you take any shop courses in school? Yes NoDrivingDo you own/have access to a car? Yes NoDo you have a valid Driver's /Operators License? Yes NoHas your Driver's/Operators License ever been revoked? Yes NoTraining and Work HistoryHave you ever been in another training program? Yes NoIf yes, give name and location of program:Dates you attended this program:Did you complete the program Yes NoEmploymentHave you ever held a job before? Yes NoIf yes, Name and Address of Company:If yes to above, Start and End Date:If yes to above, pay per week:If yes to above, Job Title:If yes to above, Supervisor's Name and Title:If yes you above, Job Description:Reason for Leaving?Current EmploymentAre you currently working? Yes NoIf Yes, is your job: Full Time Part TimeIf employed, current hourly wage per hour:Number of hours, on average, you work each week:Construction/ Hospitality ExperienceHave you had any construction experience? Yes NoWas it a paid experience? Yes NoPlease describe this experience:Have you had any hospitality experience? Yes NoWas it a paid experience? Yes NoPlease describe this experience:Mental Health HistoryHave you ever been diagnosed with a mental health condition? Yes NoIf yes, please give date and diagnosisDo you take any medication(s)? Yes NoIf yes, what medication(s) do you take and how often?Have you ever been hospitalized for any medical, emotional or mental health reasons? Yes NoIf yes, when and why?Do you identify with the LGBTQIA+(Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, Asexual, and A gender +) Community? Yes NoEmergency Contact InformationName First Last RelationshipPhoneName First Last RelationshipPhoneName First Last RelationshipPhoneSupportsName at least two people that have been positive influences or role models in your lifeHow have these persons been influential in your life?
