We Are the Youth Outreach PYE Program Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Full Name *

First Name Middle Name Last Name
*
Example: 1234
Student Birth Date *

Month Day Year
Student Phone Number *
Student E-mail *
example@example.com
Please verify your email

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Student Gender
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you over 18 years old? *

No Yes
What School do you attend?
What grade are you in? *

Ninth Grade Tenth Grade Eleventh Grade Twelve Grade I graduated form school I attend college I dropped out of school Other
Have you been employed before? *

Yes No This will be my first job
Do you have a resume? *

No Yes I need your help to create a resume Other
Will you have reliable transportation to and from work, if hired? *

No Yes I will catch the bus I will catch an Uber/Lyft My guardian will take me to and from work Other
Select the time frame that you prefer to work, if hired? (select all that apply) *

Morning Afternoon Evening Night Overnight Other
Do you have to report to any of the following? *

Probation Officer Case Manager Mentor Judge No, I do not have to report to anyone Other
Do you have a felon?

No Yes
If you said yes to having a felon, please explain below
Note: some jobs prefer not to hire based on background, but this does not automatically disqualify you.
Do you have a misdemeanor?

No Yes
If you said yes to having a misdemeanor, please explain below
Note: some jobs prefer not to hire based on background, but this does not automatically disqualify you.

Emergency Contact Information Section
Parent or Legal Guardian Full Name *

First Name Last Name
Parent or Legal Guardian Phone Number *
Please enter a valid phone number.
Parent or Legal Guardian Alternate Number
Parent or Legal Guardian Email
example@example.com
Additional Comments
Please list anything that you would like us to know in this box. Ex. Skills, Training, Job Preference, Availability
Please sign in this box before submitting your application *

Clear
Please verify that you are human *
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Student Registration Form