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
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
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
Single
Married
Separated
Divorced
Widowed
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
Active
Inactive
None
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
Submit
Should be Empty: