YBL Student Application Form

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
Name: *

First Name Middle Name Last Name
Assigned Case Manager Name *
Ask if you don't have one yet or don't know name.
Program Start Date *

Month Day Year
Date
Check ALL that apply. I am a member of: *

YouthBuild Louisville Training YHDP Housing Urban Conservation Corps
Birth Date *

Month Day Year
Age *
Your age today
Phone Number: *

Area Code Phone Number
E-mail Address: *
Your Email Address
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Other Number: Family, Friend, Work

Area Code Phone Number
Name of Family, Friend, Work

First Name Last Name
Race *

Hawaiian Native or other Pacific Islander American Indian or Alaskan Hawaiian African American Caucasian Asian
Do you have a diagnosed disability? *

None Physical Disability Visual Impairment Hearing Impairment Speech / Language Impairment Intellectual Disability Specific Learning Disability Autism Spectrum Disorder
Do you have any of the following conditions? *

HIV/AIDS Substance Abuse Issue Alcohol Abuse Issue Prefer not to disclose at this time.
Gender *

Male Female Transgender (M-F) Transgender (F-M) Gender Nonconforming
Do you identify as LBGTQ? *

Yes No
Participant Type *

Current or Former Youth in Foster Care Referred by Guidance Counselor Child of Incarcerated Parent Low-Income Family Youth Offender Adult Offender Migrant Youth
Criminal Justice Information:
Received Pre-Release Services *

Yes No
Pre-Release Contract *

Yes No
Referral Source *
Mandated Enrollment *

Yes No
Alternative Sentence *

Yes No
Probation/ Parole *

Yes No
Date of Most Recent Probation

Month Day Year
Date of Most Recent Contact with Probation/Parole Officer

Month Day Year
Type of Contact with Probation/ Parole Officer *

Email or Written Report In Person Phone
Name of Probation / Parole Officer

First Name Last Name
Phone Number of Officer

Area Code Phone Number
Assessment Information
Mental Toughness Completed *

Yes No
Basic Skill Deficient *

Yes No
TAP Participant *

Yes No
Co-Enrolled in WIOA (KYCC) *

Yes No
Are you a Veteran? *

Yes No
Registered for Selective Service? (NOTE: If you are Male and 18+ years old, you MUST be registered. We will help you complete this process.) *

Yes No Not Applicable (Female or under 18)
Are you currently employed? *

Yes No Employed, but on notice of Termination or Military Separation
Where are you employed? *
Ex: Wendy's, Kroger, Neil's Roofing
Occupation Title *
Ex: Cook, Cashier, Waitress
Weekly Hours at Enrollment *
ex: 30
Hourly Wage at Enrollment *
Ex: $9.75
Start Date of Employment *

Month Day Year
Are you a U.S Citizen? *

Yes No
Authorized to work? *

Yes No
Are you registered to Vote? *

Yes No
Do you have the following: *

Driver's Permit Driver's License None of above
What source of transportation do you primarily use? *

Walk Bicycle Bus/ Public Transportation Personal Vehicle Shared Ride / Friends & Family
Housing, Family, & Education
Housing Status at Enrollment *

Staying at someone's apartment, room, or house (Unstable) Staying at someone's apartment, room or house (Stable) Staying with Foster Guardian/ in Foster System Rent/ Own Apartment, Room or house Halfway house/ Transitional House Residential Treatment Living with Family Homeless
If you selected "YES" to homeless in above question, what was the approximate start date of homelessness?

Month Day Year
Date
Have you been in any of the following institutions in the last 12 months? *

Foster Care/ Group Home Jail Prison Juvenile Detention Center Psychiatric Hospital Substance Abuse Treatment or Clinic N/A (if does not apply.)
Completed Certifications. Select all you have obtained.

OSHA Safe Serv Forklift
Alcohol Abuse / Illegal Drug Use at Enrollment *

Yes No
Marital Status: *

Single Married Domestic Partner Divorced Separated Widowed
Number of Children of Participant *
Ex: 2
Children living with Participant *
Ex: 2
Are you currently expecting a child? *

Yes No
Do you need childcare? *

Yes No
Other Dependents Living with Participants *
Ex: Relatives, Friends, Domestic Partners
Did you drop out of High School? *

Yes No
Highest School Grade Completed *
Ex: Relatives, Friends, Domestic Partners
How many years have you been out of school? *
Ex: Relatives, Friends, Domestic Partners
Did you have an educational credential? *

High School Diploma High School Equivalency (GED) or (HiSet) Some College No Credential
If you enroll in post secondary education, will you be a 1st generation enrollee? *

Yes No
What is your initial desired post-secondary education credential ? *

Associates degree Bachelor's degree Graduate/Professional degree Certificate Apprenticeship placement Employment only Undeclared Unknown
Is English your first language? *

Yes No
Additional Information
Household Income: *

None $1 - $10,000 $10,001 - $20,000 $20,001 - $30,000 $30,001 - and above
Public Assistance (Indicate ALL that apply as of today) *

Welfare for Single Adults or General Assistance Unemployment Insurance Food Stamps (SNAP) SSI, SSD, SSA TANF/K-TAP Public Assistance/ Non-TANF Public Housing Other Government Sources No Benefits
Medical Benefits (Indicate ALL that apply as of today) *

Private Health Insurance from Work or Family Member Medicare Medicaid None
Mental Health Treatment *

Yes No
Are you a domestic violence survivor? *

Yes No
Child Support Obligation at Enrollment *
Number of Children you pay child support for.
Child Support Obligation - Amount *
How much $ per month is paid.
Public Assistance Prior to Enrollment (Check all that apply) *

Welfare for Single Adults or General Assistance Unemployment Insurance Food Stamps (SNAP) SSI, SSD, SSA TANF/K-TAP Public Assistance/ Non-TANF Public Housing Other Government Sources No Benefits
Amount of Public Assistance Prior to Enrollment (Check all that apply) *
$ per Month
Duration of Public Assistance Prior to Enrollment (Number of Months) *
# of Months
Medical Benefits Prior to Enrollment *

Private Health Insurance from Work or Family Member Medicare Medicaid None
What additional services are you interested in? Select your top (3): *

Medical Counseling/Mental Health/Support Groups Financial Aid Public Assistance Child Care Assistance Life Skills (Cooking, Organization) Money Management/ Financial Wellness Clothing Food Resources Rental Assistance Housing Assistance Legal Assistance
TABE Score

THIS SECTION REQUIRES STAFF ASSISTANCE TO COMPLETE
Reading
Reading Test Date

Month Day Year
Date
Reading - Level

E M D A
Reading NRS *
Indicate # 1-5
Reading Scale Score *
If you have not taken, write N/A.
Mathematics
Math Test Date

Month Day Year
Date
Math - Level

E M D A
Math NRS *
Indicate # 1-5
Math Scale Score *
If you have not taken, write N/A.
Learning Style
Cognitive / Receptive Learning Style *

Auditory Tactile Visual
Social Learning Style *

Individual Group
Expressive Learning Style *

Written Oral
What does your career assessment say about you?
What is your Personality/ Behavior type, and what does it say about you?
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.
Career Goal:
Ex: Nurse, Computer Engineer, Construction
Education Goal:
Ex: GED, High School Diploma, Associates Degree
Vocational Goal:
Ex: Nurse, Computer Engineer, Construction
AmeriCorps Goal:
Ex: Finish 450 Community Service Hours, 50 Hours Helping Homeless Youth, Earn Scholarship for College
Personal Goals:
Ex: Get a gym membership, eat healthier, learn how to meditate
Clothing Size

Please note you will be checked by a staff member for appropriate sizing.
Shirt Size
Jean Size
Ex: 32L, 40W
Shoe Size
Ex: 14 Men, 7 Women
Jacket Size
Recommend 1 size larger
Notes:
Height
Weight
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.
Your Initials *
Name of staff who assisted you:
Mike, Rae, Danyetta
Should be Empty:

YBL: Entry Form: Case Management Assessment

Case Management

Criminal Justice Information:

Assessment Information

Housing, Family, & Education

Additional Information

TABE Score

Reading

Mathematics

Learning Style

Goals for My Success Plan

Clothing Size

Signature