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 RemediationA2: GED PreprationA3: High School Diploma PreparationA4: Vocational / Occup. Skills TrainingA4: Lock Up LeadA4: CPRA4: HazcomA4: OSHAA4: PPEA5: On the Job TrainingA6: Computer/Environmental TrainingA7: Registered Pre-Apprenticeship
DOL CODE: B

B1: Subsidized EmploymentB2: InternshipB3: Workforce Information ServicesB4: ResumeB4: InterviewsB4: Work Readiness TrainingB5: Career/ Life Skills CounselingB6: Driver's EducationB6: Professional Guest SpeakersB6: Visits to Professional WorksitesB6: Post Graduation Plan
DOL CODE: C & D

C1: Community ServiceC2: Field Trips/Community MtgsC3: Leadership DevelopmentD1: Mentoring
DOL CODE: E

E1: Substance Abuse TreatmentE1: Drug TestE2: Mental Health TreatmentE3: Emergency Medical CareE4: Non-Emergency Medical CareE5: PregnancyE5: Healthy Relationships (love notes)E6: Eye Exams & Glasses
DOL CODE: F

F1: Childcare ServicesF2: Need Related PaymentsF3: Follow-Up MentoringF4: Tarc PassesF4: Uber ServicesF5: Alumni TutoringF5: Alumni AssesmentF6: Accessing AC ScholarshipF6: Housing
DOL CODE: G

G1: FASFAG1: College VisitsG1: Assistance Finacial AidG1: Training for Compass TestG1: ACT PrepG1: PACT College CreditG1: College App AssistanceG1: College Prep TutoringG1: Ultra ProgramG1: 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