YBL Student Application Form

YHDP: Services & Case Notes

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 supervisor.
Case Manager Name
Case Manager Email
Please enter email to receive a receipt of what's submitted.
If reporting on a Service for an Individual, please list their name. If reporting on a Service received as a Group, please select the Gold or Maroon (or both) option.
Participant Name

First Name Last Name
Date of Service *
DOL SERVICE PROVIDED

Select all that apply:
DOL CODE: A

A1: Math & Reading Remediation A2: GED Prepration A3: High School Diploma Preparation A4: Vocational / Occup. Skills Training A4: Lock Up Lead A4: CPR A4: Hazcom A4: OSHA A4: PPE A5: On the Job Training A6: Computer/Environmental Training A7: Registered Pre-Apprenticeship
DOL CODE: B

B1: Subsidized Employment B2: Internship B3: Workforce Information Services B4: Resume B4: Interviews B4: Work Readiness Training B5: Career/ Life Skills Counseling B6: Driver's Education B6: Professional Guest Speakers B6: Visits to Professional Worksites B6: Post Graduation Plan
DOL CODE: C & D

C1: Community Service C2: Field Trips/Community Mtgs C3: Leadership Development D1: Mentoring
DOL CODE: E

E1: Substance Abuse Treatment E1: Drug Test E2: Mental Health Treatment E3: Emergency Medical Care E4: Non-Emergency Medical Care E5: Pregnancy E5: Healthy Relationships (love notes) E6: Eye Exams & Glasses
DOL CODE: F

F1: Childcare Services F2: Need Related Payments F3: Follow-Up Mentoring F4: Tarc Passes F4: Uber Services F5: Alumni Tutoring F5: Alumni Assesment F6: Accessing AC Scholarship F6: Housing
DOL CODE: G

G1: FASFA G1: College Visits G1: Assistance Finacial Aid G1: Training for Compass Test G1: ACT Prep G1: PACT College Credit G1: College App Assistance G1: College Prep Tutoring G1: Ultra Program G1: KY Loop Program
Description of Services
Case Notes
Please provide 5-7 sentences about the Services Provided. *
Should be Empty:

YHDP: Services & Case Notes

DOL SERVICE PROVIDED

Case Notes