Youth Service Programs Application Form

MEO Youth Service Programs Application Form
Aloha and Welcome to Maui Economic Opportunity (MEO) Youth Services! We are proud to offer a variety of opportunities to develop and enrich Maui’s youth in a safe and positive environment.

Please CHECK one or more of the NO COST programs that we offer, and staff will contact you with the details.
Prevention Courses (Virtual Only)
Each Course consists of 5 one-hour sessions. (Offered Year Round)

Slick Tracy (For 5th to 7th graders)– A comic books series that focuses on the effects of underage drinking and promotes youth and parent communication.Class Action (For 9th to 12th graders)– Youths will examine 6 civil trial cases dealing with the consequences of youth and alcohol use.Gatekeepers and Digital Defenders (For 7th to 12th graders)– Youths will learn about risk and protective factors, warning signs and connecting someone who is suicidal to the proper help they need. Including information on the “Bullying Circle” and steps on how to report an online cyberbully.
Youth Services Program
For Middle and High Schoolers, programs are offered year round. Transportation is provided to and from each activity. COVID Restrictions Apply.

After-School Program: Two Service-Learning Activities per week (possibly on weekends) Each Activity is from 2 to6 p.m. Activities include community service, tutoring, life skills, and cultural connectedness.Out-of-School Program: Activities during Summer, Fall, Winter, and Spring Breaks Four Service-Learning Activities per week (possibly nights and weekends) Each Activity is from 8 a.m. to 4 p.m.M.A.U.I. Kanaktion Task Force: Meet once a month from 5 to7 p.m. Receive Leadership and Mentorship Training Create local prevention campaigns (alcohol, tobacco, suicide, bullying)Kamp Ka'ohi (MOLOKA'I): Fun overnight camp filled with games and educational activities that foster healthy prevention factors and creates empowered prevention leaders in the community.
Youth Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
Age*
Sex*

MaleFemaleOtherUnknown
Education Level*

0-89-12/non-graduateHigh School Grad / GED12+ some post secondary2 to 4 year College graduate
Health Insurance*

No InsuranceMedicaidMedicareState Children's Health Ins.State Adult Health Ins.Military Health CareDirect-PurchaseEmployment BasedUnknown
Race*

WhiteMulti-race (2 or more)African American or BlackAsianNative Hawaiian & Other Pacific IslanderAmerican Indian/Alaskan NativeUnknownOther
Ethnicity*

Hispanic, Latino or Spanish originNOT Hispanic, Latino or Spanish originUnknown
Disabling Condition?*

YesNo
Disconnected Youth - Youth 14-24 not working or in school*

YesNo
Physician, Address and Telephone Number
List Allergies (Food or Drug)
List Medications
Parent Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Family Information
Housing*

OwnRentHomelessOther permanent Housing
Family/Household Size*

One memberTwo membersThree membersFour membersFive membersSix members or more
Family/Household Type*

Single PersonSingle Parent FemaleSingle Parent MaleTwo Parent HouseholdTwo Adults NO ChildrenNon-related With/ChildrenMulti-generational Household
Source of Family Income*

Employment ONLYEmployment + Other ONLYEmployment + Other + Non-cash BenefitsEmployment + Non-cash BenefitsOther Sources ONLYOther + Non-cash BenefitsNO IncomeNon-Cash Benefits ONLY
Other Income Source*

TANFSSIVA Service disability CompVA Non-Service Disability PensionPrivate Disability InsuranceWorkers CompensationRetirement Income from Social SecuritySocial Security Disability Insurance (SSDI)Unemployment InsurancePensionChild SupportAlimony or other Spousal SupportUnemployment InsuranceEITC
Non-Cash Benefits*

SNAPWICLIHEAPHousing Choice VoucherPublic HousingPermanent Supportive HousingHUD - VASHChildcare VoucherAffordable Care Act Subsidy
Select Household Size and Income*
Select which services You or Your family have received or participated in from MEO in the past year.*

NoneTransportationEarly Childhood Services - Head Start / Kahi Kamali'iReintegration ServiceEnergy AssistanceRental AssistanceFinancial Literacy TrainingEnlace HispanoSenior Citizen "Red Card" ProgramNational Farm-worker Jobs ProgramSenior ScoopYouth Services Program
Participant's Waiver of Claim and Indemnity
Emergency Contact Information
Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Signature*

Clear
Should be Empty:

MEO Youth Service Programs Application Form

Prevention Courses (Virtual Only)

Youth Services Program

Youth Information

Parent Information

Family Information

Participant's Waiver of Claim and Indemnity

Emergency Contact Information