Program Eligibility Application
Ohio Department of Job and Family Services- JFS 03002
Applicant Name (First, Middle Initial, Last)
*
(ex. Joseph A. Buckeye)
Application Status
Please Select
Incomplete
Approved
Not Eligible
Hold for Later
What high school do you attend?
*
(ex. West High School, The Charles School, etc.)
What is your grade level?
*
Please Select
9
10
11
12
Other
If a Lead The Way staff person helped you with this application, what is their name?
*
Please Select
Coach Chris Williams
Coach Chad Tennant
Coach Brandy Berry
Coach Clarke Fann
Coach Alexis Parks
Coach Allen Costa
If a Lead The Way staff person helped you with this application, what is their email address?
*
Please Select
Allen@leadthewaylearningacademy.org
Brandy@leadthewaylearningacademy.org
Chad@leadthewaylearningacademy.org
Chris@leadthewaylearningacademy.org
Clarke@leadthewaylearningacademy.org
Lex@leadthewaylearningacademy.org
What is your home address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
If for some reason we're not able to contact you on your primary number, do you have another personal number? This could include the phone number of a sibling, close friend or someone who would not be considered an emergency contact. (optional)
Please enter a valid phone number.
Primary Email
*
example@example.com
Alternate Email
*
example@example.com
Parent/Guardian Full Name
*
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Do you have a Driver's License or Temporary Permit?
*
Yes
No
What type of government-issued identification do you have?
*
Please Select
Non-Commercial Driver's License
Non-Commercial Drive's Permit
Commercial Driver's License
State ID
Passport
Birth Certificate
When does your government-issued identification expire?
*
-
Month
-
Day
Year
Date
Please upload a copy or photo of your government-issued ID.
*
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Ex. Driver's License; State, Federal, or Local Government ID; Passport
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Please upload a copy of your birth certificate.
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of
What is your gender?
*
Male
Female
Other
What is your education level?
*
Withdrew from high school, no HS diploma
Current high/junior high school student
Completed 12th grade, but no HS diploma
Obtained high school or equivalent diploma
High school graduate
Some post high school education, no degree
College degree
If you have a college degree, what type is it?
Associate
Bachelor
Masters/Professional
What is your education status?
*
I am not a student
I am a student at a college or technical school
I am a student in a high school equivalency program
I am a high school student, at grade level
I am a high school student, behind grade level
I am not attending high school
Please upload verification of current school status.
*
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Ex. School ID Card with Photograph, Class Schedule, etc.
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What is your date of birth?
*
-
Month
-
Day
Year
Date
What is your ethnicity?
*
Hispanic/Latino
Not Hispanic/Latino
What is your race?
*
Black/African American
Asian
American Indian
Hawaiian Islander or Other Pacific Islander
White
Alaskan Native
Other
What is your native or primary language?
*
Have you registered for Selective Service (for males >18)?
*
Yes
No
Not Applicable (ex. under 18, female)
Please upload verification of Selective Service Registration (Males 18+)
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Ex. Selective Service Card; Verification from Selective Service Website: https://www.sss.gov/
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of
What is your citizenship status?
*
US Citizen
Undocumented
Refugee
Authorized to work in the U.S- Documented
Documented
Other Legal Alien
Other
Please upload a copy of your Social Security Card.
*
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Have you been or are you a member of a family who received public cash assistance or SNAP in the last 6 months?
*
Yes
No
If you answered "yes" to receiving cash assistance or SNAP, please upload verifying documentation. (Ex. Authorization Form, Verification from Public Assistance Agency, etc.)
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Do you have a disability?
*
Yes
No
If you answered "yes" to having a disability, please upload verifying documentation. (Ex. Letter from drug or alcohol rehabilitation agency, medical records, physician's statement, psychologist diagnosis, social security disability records, school record of disability determination, etc.).)
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Are you pregnant?
*
Yes
No
If you answered "yes" to being pregnant, please upload verifying documentation. (Ex. Physician's Statement, etc.)
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Do you have any minor children?
*
Yes
No
If English is not your native or primary language, do you need help learning to speak/write/use English?
*
Yes
No
Are you homeless?
*
Yes
No
Are you a runaway?
*
Yes
No
Are you in foster care or were you previously in foster care?
*
Yes
No
Are you involved or were you involved in the juvenile court or adult justice system?
*
Yes
No
If you answered "yes" to being involved in the juvenile court or adult justice system, please upload supporting documentation. (Ex. Court records, letter of parole, police records, etc.)
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Do you receive or are you eligible to receive free or reduced-price lunch?
*
Yes
No
If you answered "yes" to receiving or being eligible to receive free or reduced-price lunch, please upload supporting documentation. (Ex. Approval Letter, Completed Application, etc.)
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Do you need reliable child care? (For any children under your care that would need supervision if you were working. Ex. younger siblings, children, etc.)
*
Yes
No
Are you a single parent?
*
Yes
No
Are you caring for an adult relative with a disability?
*
Yes
No
Do you need reliable dependent care? (For anyone under your care with special needs.)
*
Yes
No
Do you have stable housing?
*
Yes
No
Do you use recreational drugs regularly?
*
Yes
No
Do you drink alcohol regularly?
*
Yes
No
Do you have reliable transportation? (I.e. Do you have your own reliable vehicle and driver's license?)
*
Yes
No
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Do you provide more than 50% of your own support? In other words, do you pay for more than half of your bills and expenses including phone, food, clothes, shelter, transportation, etc?
*
Yes
No
Are you married or separated but not divorced?
*
Yes
No
Do you have children who receive more than half of their support from you?
*
Yes
No
Do you have dependents (other than your children or spouse) who live with you and who receive more than half of their support from you?
*
Yes
No
Do you live in your own residence or in a residence without support from a parent(s) or a guardian(s)?
*
Yes
No
Are you currently serving on active duty in the U.S. Armed Forces or are you serving on active duty as an enlistee of the National Guard or Reserve for purposes other than training?
*
Yes
No
Are you a veteran of the U.S. Armed Forces?
*
Yes
No
Did you answer "Yes" to any of the questions on this page?
*
Yes
No
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Household Income
Please complete the following for EVERY member of your household, including all adults and minor children that live with you.
What is your full name? (Name of applicant)
*
Are you currently employed?
*
Yes
No
If you're employed, what was your personal gross income (before taxes) from the last 30 days?
If you're employed, please upload your paystub or income verification from the last 30 days.
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The document should have your name on it.
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Name 1 (What is the full name of another member of your household?)
*
Relationship 1 (How is this person related to you? Ex. Mother, Brother, Son)
*
Monthly Income 1 (How much does this person earn per month before taxes?)
*
Please upload paystub or income verification for Household Member 1 (if older than 17) from the last 30 days.
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Name 2 (What is the full name of another member of your household?)
Relationship 2 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 2 (How much does this person earn per month before taxes?)
Please upload paystub or income verification for Household Member 2 (if older than 17) from the last 30 days.
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Name 3 (What is the full name of another member of your household?)
Relationship 3 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 3 (How much does this person earn per month before taxes?)
Please upload paystub or income verification for Household Member 3 (if older than 17) from the last 30 days.
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Name 4 (What is the full name of another member of your household?)
Relationship 4 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 4 (How much does this person earn per month before taxes?)
Please upload paystub or income verification for Household Member 4 (if older than 17) from the last 30 days.
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Name 5 (What is the full name of another member of your household?)
Relationship 5 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 5 (How much does this person earn per month before taxes?)
Please upload paystub or income verification for Household Member 5 (if older than 17) from the last 30 days.
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Name 6 (What is the full name of another member of your household?)
Relationship 6 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 6 (How much does this person earn per month before taxes?)
Name 7 (What is the full name of another member of your household?)
Relationship 7 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 7 (How much does this person earn per month before taxes?)
Name 8 (What is the full name of another member of your household?)
Relationship 8 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 8 (How much does this person earn per month before taxes?)
Name 9 (What is the full name of another member of your household?)
Relationship 9 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 9 (How much does this person earn per month before taxes?)
Name 10 (What is the full name of another member of your household?)
Relationship 10 (How is this person related to you? Ex. Mother, Brother, Son)
Monthly Income 10 (How much does this person earn per month before taxes?)
Disclosure of Relationship- Do you have a business/personal relationship with any individual who is a 1) Local elected official (mayor or county commissioner), 2) Workforce Development Board member or subcommittee member, 3) WIOA executive, supervisor, or employee, 4) OhioMeansJobs center employee, partner employee, WIOA sub-recipient and/or contractor, or 5) CDJFS or other county employee?
*
Yes
No
If you answered yes to the previous question, what is the person's name?
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Are you or your family currently receiving cash assistance or SNAP?
*
Yes
No
How many people live in your household?
*
1
2
3
4
5
6
7
8
9
10
What is your total household monthly gross income in the last 30 days (before taxes)?
*
Was the households' gross income during the past 30 days less than than 200% of the Federal Poverty Line for the household size?
Yes
No
Do you have a child under the age of 18?
*
Yes
No
How many children do you have?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
What is the age of your oldest child? (optional)
Are you one of the following? (1) A minor child (2) A parent, specified relative, legal guardian or legal custodian of a minor child (3) a non-custodial parent (4) a pregnant individual (5) an individual age 18-24 that is part of a family that includes a minor child
*
Yes
No
Have you been given the opportunity to register to vote?
*
Yes
No
Are you currently repaying fraudulent public assistance (cash)?
*
Yes
No
Parent/Guardian Signature (if applicant is under age 18)
Clear
Parent/Guardian Signature Date
-
Month
-
Day
Year
Date
Applicant Signature
*
Clear
Applicant Signature Date
*
-
Month
-
Day
Year
Date
What is the best time of day for us to follow-up with you by phone? Please select a time when both the youth applicant and the parent/guardian will be available.
*
Please Select
10:00am-12:00pm
12:00pm-2:00pm
2:00pm-4:00pm
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WIOA Funding Eligibility Determination
This section is only to be completed by the Quality Assurance Team once all documentation and information has been collected and verified. If you have any questions or feedback, please contact ernest@leadthewaylearningacademy.org.
Is the individual attending school (high school, college, technical school)?
Yes
No
If yes, is the individual low-income or live in a high-poverty area under WIOA?
Yes
No
Other
Does the individual have a documented WIOA barrier to employment?
Yes
No
If yes, what is the documented WIOA barrier to employment?
Please Select
Basic Skills Deficient
English Language Learner
Justice System Involvement/Offender
Homeless or Runaway
In Foster Care/Aged Out of Foster Care
Pregnant
Parenting
Individual with a Disability
Requires Additional Assistance
Is the individual basic skills deficient? (If yes, may need income data)
Yes
No
Does the individual require additional assistance as defined by your local area policy?
Yes
No
Is the individual authorized to work in the United States?
Yes
No
If the individual is a male over age 18, has he registered for Selective Service?
Yes
No
TANF Funding Eligibility Determination
Is the household's monthly income under 200% of the Federal Poverty Guidelines for the current year?
Yes
No
Does the individual have a child under age 18?
Yes
No
Does the individual owe any fraudulent TANF assistance paid to the individual?
Yes
No
Is the individual one of the following: (1) A minor child (2) a specified relative, legal guardian or legal custodian of a minor child (3) a non-custodial parent (4) a pregnant individual (5) an individual age 18-24 that is part of a family that includes a minor child?
Yes
No
If yes to the previous question, which of the following applies?
Please Select
A minor child
A specified relative, legal guardian or legal custodian of a minor child
A non-custodial parent
A pregnant individual
An individual age 18-24 that is part of a family that includes a minor child?
WIOA Funding Eligibility Determination
WIOA In-School Youth Program eligible and low income
5% Low-Income Exception for WIOA
WIOA Out-of-School Youth Program Eligible
Ineligible for WIOA Funding
TANF Funding Eligibility Determination
TANF Funding Eligible
Ineligible for TANF Funding
Signature of TANF Eligibility Staff
Clear
Date
-
Month
-
Day
Year
Date
Signature of WIOA Eligibility Staff
Clear
Date
-
Month
-
Day
Year
Date
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