• YBL: Entry Form: Case Management Assessment

    This form is for ALL participants of any YouthBuild affiliate program. Please read all of the questions and guidelines carefully, taking time to answer fully. Note that some questions will have an "ex:" (example) answer to help guide you. If you need further assistance in completing the form, please ask a staff member.
  • Case Management

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    Pick a Date
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  • Criminal Justice Information:


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  • Assessment Information

  • Housing, Family, & Education


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  • Additional Information






  • TABE Score

    THIS SECTION REQUIRES STAFF ASSISTANCE TO COMPLETE
  • Reading

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  • Mathematics

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    Pick a Date
  • Learning Style

  • Goals for My Success Plan

    Write three goals for each question. Each goal should be a SMART Goal: Specific, Measurable, Achievable, Realistic and Time-Based.
  • Clothing Size

    Please note you will be checked by a staff member for appropriate sizing.
  • Signature

    I HEREBY CERTIFY THAT THE ANSWERS GIVEN BY ME ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER CERTIFY THAT I, THE UNDERSIGNED APPLICANT, HAVE PERSONALLY COMPLETED THIS APPLICATION. I VERIFY BY MY SIGNATURE THAT THE ABOVE ADDRESS IS MY CORRECT LIVING ADDRESS. I HEREBY AUTHORIZE YOUTHBUILD LOUISVILLE TO THOROUGHLY INVESTIGATE MY WORK RECORD, EDUCATION AND OTHER MATTERS RELATED TO MY SUITABILITY FOR ACCEPTANCE INTO THE PROGRAM. PLEASE ENTER YOUR INITIALS IN THE SPACE BELOW, INDICATING YOUR AGREEMENT TO THE TERMS LISTED ABOVE. YOUR INITIALS IN THE SPACE BELOW ACT AS YOUR SIGNATURE TO THIS DOCUMENT.
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