MEO Youth Service Programs Application Form

MEO Youth Service Programs Application Form
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Birthdate

Month Day Year
Date
Sex

Male Female Other Unknown
Health Insurance

No Insurance Medicaid Medicare State Children's Health Ins. State Adult Health Ins. Military Health Care Direct-Purchase Employment Based Unknown
Race

White Multi-race (2 or more) African American or Black Asian Native Hawaiian & Other Pacific Islander American Indian/Alaskan Native Unknown Other
Ethnicity

Hispanic, Latino or Spanish origin NOT Hispanic, Latino or Spanish origin Unknown
Age
Disabling Condition?

Yes No
Disconnected Youth - Youth 14-24 not working or in school

Yes No
Work Status - Individuals 18+

Employed, Full-time Employed, Part-time Migrant Seasonal Farm-worker Retired Unemployed (6 months or less) Unemployed (Long-term for more than 6 months) Unemployed, (Not in labor force)
Marital Status
Housing

Own Rent Homeless Other permanent Housing
Education Level

0-8 9-12/non-graduate High School Grad / GED 12+ some post secondary 2 to 4 year College graduate
Military Status
Family/Household Size

One member Two members Three members Four members Five members Six members or more
Family/Household Type

Single Person Single Parent Female Single Parent Male Two Parent Household Two Adults NO Children Non-related With/Children Multi-generational Household
Source of Family Income

Employment ONLY Employment + Other ONLY Employment + Other + Non-cash Benefits Employment + Non-cash Benefits Other Sources ONLY Other + Non-cash Benefits NO Income Non-Cash Benefits ONLY
Other Income Source

TANF SSI VA Service disability Comp VA Non-Service Disability Pension Private Disability Insurance Workers Compensation Retirement Income from Social Security Social Security Disability Insurance (SSDI) Unemployment Insurance Pension Child Support Alimony or other Spousal Support Unemployment Insurance EITC
Non-Cash Benefits

SNAP WIC LIHEAP Housing Choice Voucher Public Housing Permanent Supportive Housing HUD - VASH Childcare Voucher Affordable Care Act Subsidy
Select Household Size and Income
Other Information
Have you or anyone in your household received any of the following service from MEO in the past year? (Choose all that apply)

You Household Members None
Select which services YOU have received or participated in from MEO in the past year (Choose all that apply)

None AmeriCorps Transportation Head start BEST LIHEAP Maui County Rental Assistance State Housing Placement Program Financial Literacy Training Enlace Hispano Senior Citizen "Red Card" Program National Farm-worker Jobs Program Theresa Hughes Senior Scoop Senior Legal Services Geist Foundation ‘Ohana Strengthening Veterans Transportation Youth Services Girls Circle/Boys Council Youth Substance Abuse Prevention Youth Services Program
Select which services OTHERS in your household have received or participated in from MEO in the past year

None AmeriCorps Transportation Head start BEST LIHEAP Maui County Rental Assistance State Housing Placement Program Financial Literacy Training Enlace Hispano Senior Citizen "Red Card" Program National Farm-worker Jobs Program Theresa Hughes Senior Scoop Senior Legal Services Geist Foundation ‘Ohana Strengthening Veterans Transportation Youth Services Girls Circle/Boys Council Youth Substance Abuse Prevention Youth Services Program
Participant's Waiver of Claim and Indemnity
Medical Information
Physician, Address and Telephone Number
List Allergies (Food or Drug)
List Medications
Emergency Contact Information
Name

First Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Signature *

Clear
Should be Empty:

MEO Youth Service Programs Application Form

Other Information

Participant's Waiver of Claim and Indemnity

Medical Information

Emergency Contact Information