Empower Queens Youth Program Application
Thank you for your interest in the Empower Queens Youth Program. Please complete this application to tell us more about yourself. Everything included will be kept confidential. We will contact you to schedule an interview if you fit our program requirements.
Personal Information
Full Name
First Name
Middle Name
Last Name
Preferred Name (If Different from your first name)
Which most closely describes your gender identity?
Please Select
Woman
Man
Transgender Woman
Transgender Man
Two Spirit
Non-Binary
Agender/I don’t identify with any gender
Gender Not Listed.
Prefer not to state
Preferred Pronoun
She/Her
He/Him
They/Them
Other
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best Way To Contact You
Text
Email
Call
Any
Which category best describes you?
American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc)
Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc)
Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc)
Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc)
Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc)
Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc)
White (Eg: German, Irish, English, Italian, Polish, French, etc)
Other
Date of Birth
-
Month
-
Day
Year
Date
Current Age
Please Select
16
17
18
19
20
21
22
23
24
What is your primary language?
Please Select
Albanian
Arabic
Bengali
Chinese (Including Cantonese & Mandarin)
English
French
Fulani
German
Gujarati
Haitian Creole
Hebrew
Hindi
Hungarian
Italian
Japanese
Korean
Kru, Ibo, Yoruba
Mande
Persian
Polish
Portuguese
Punjabi
Romanian
Russian
Spanish
Tagalog
Turkish
Urdu
Vietnamese
Yiddish
Other
Health Information
Do you have health insurance?
Please Select
Yes
No
I Don't Know
Prefer Not To Say
If YES, Please Specify The Health Insurance DownBelow (Check All That Apply)
Medicaid
Direct-Purchase
Military Health Care
Medicare
Employment-Based
State Children's Health Insurance for Adults
I don't know
Decline Not to Answer
Other
HOUSEHOLD INFORMATION
You Live in a Household That Is Headed By (Select One):
Please Select
Single Parent - Female
Single Parent - Male
Two Adults- No Children
Two Parent Household
Single Person- No Children
Multigenerational Household
Non-related Adults with Children
How many people live in your household?
Total Annual Household Income
Please Select
Less than $20,000
$21,001-40,000
$40,001-$60,000
Over $60,001
Not Sure
Please Select Your Housing Type:
Own
Rent
Shelter
Homeless/Unhoused
Other
Are You or Your Family Currently Receiving Public Assistance?
Please Select
Yes
No
If YES, Please Specify Type of Public Assistance:
Family Assistance
Safety Net/ Home Relief
SNAP (Supplemental Nutrition Assistance Program)
S.S.I
Other
Do You Have Access to An Electronic Device With InternetAccessibility?
Please Select
Yes
No
Do You Have a Bank Account?
Please Select
Yes
No
EDUCATIONAL & CAREER
What is Your Education Status?
Please Select
Current H.S. Student- Full Time
Current H.S. Student- Part Time
Current TASC/GED Program Student
Current College Student- Full Time
Current College Student- Part-Time
Graduated from H.S./Not In School
Graduated from College/Not In School
Never Graduated/Not In School
What is Your Current Work Status ?
Please Select
Employed Full-Time Unemployed (Not In Labor Force)
Employed Part-Time
Migrant Seasonal Farm Worker
Unemployed (Short-term, 6 months or less)
Unemployed (Long-term, more than 6 months)
Do You Have Prior Work Experience (Paid or Unpaid)?
Please Select
Yes
No
If in school, what is the name of your high school/college/university?
ADDITIONAL QUESTIONS
Are You Currently In The Foster Care System?
Please Select
Yes
No
Do You Have a Disability?
Please Select
Yes
No
Are You an Offender or Court Involved?
Please Select
Yes
No
Are you a Gender-Based/ Domestic Violence Victim?
Please Select
Yes
No
Are You a Parent or a Guardian of a Child or Sibling?
Please Select
Please Select Your Citizenship Status
Please Select
U.S. Citizen
Permanent Resident
DACA Recipient
Undocumented
Are You Receiving ACS Preventative Services?
Please Select
Yes
No
Unsure
EMERGENCY CONTACT INFORMATION
Emergency Contact Name
First Name
Last Name
Emergency Contact Email
example@example.com
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship to You (ie. Mother, Aunt, Family Friend)
Submit
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