YBL: Entry 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

  • Program Start Date*
     - -
  • Check ALL that apply. I am a member of:*
  •  -
  •  -
  • Race*

  • Do you have a diagnosed disability?*

  • Do you have any of the following conditions?*

  • Gender*

  • Do you identify as LBGTQ?*
  • Participant Type*

  • Criminal Justice Information:

  • Received Pre-Release Services*
  • Pre-Release Contract*
  • Mandated Enrollment*
  • Alternative Sentence*
  • Probation/ Parole*
  • Type of Contact with Probation/ Parole Officer*

  •  -

  • Assessment Information

  • Mental Toughness Completed*
  • Basic Skill Deficient*
  • TAP Participant*
  • Co-Enrolled in WIOA (KYCC)*
  • Are you a Veteran?*
  • Registered for Selective Service? (NOTE: If you are Male and 18+ years old, you MUST be registered. We will help you complete this process.)*
  • Date of Selective Service Verification:
     - -
  • Have you been employed in the past 6 months?*
  • Are you currently employed?*
  • Are you a U.S Citizen?*
  • Authorized to work?*
  • Are you registered to Vote?*
  • Do you have the following:*
  • What source of transportation do you primarily use?*

  • Housing, Family, & Education

  • Housing Status at Enrollment*

  • If you selected "YES" to homeless in above question, what was the approximate start date of homelessness?
     - -
  • Have you been in any of the following institutions in the last 12 months?*
  • Completed Certifications. Select all you have obtained.

  • Alcohol Abuse / Illegal Drug Use at Enrollment*
  • Marital Status:*
  • Are you currently expecting a child?*
  • Do you need childcare?*
  • Did you drop out of High School?*
  • Did you have an educational credential?*
  • If you enroll in post secondary education, will you be a 1st generation enrollee?*
  • What is your initial desired post-secondary education credential ?*
  • Is English your first language?*

  • Additional Information

  • Household Income:*

  • Public Assistance (Indicate ALL that apply as of today)*

  • Medical Benefits (Indicate ALL that apply as of today)*

  • Mental Health Treatment*
  • Are you a domestic violence survivor?*
  • Public Assistance Prior to Enrollment (Check all that apply)*

  • Medical Benefits Prior to Enrollment*

  • What additional services are you interested in? Select your top (3):*

  • TABE Score

    THIS SECTION REQUIRES STAFF ASSISTANCE TO COMPLETE

  • Reading

  • Reading Test Date
     - -
  • Reading - Level

  • Mathematics

  • Math Test Date
     - -
  • Math - Level

  • Learning Style

  • Cognitive / Receptive Learning Style*
  • Social Learning Style*
  • Expressive 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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