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)
Youth Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birthdate

Month Day Year
Date
Age
Sex

Male Female Other Unknown
Education Level

0-8 9-12/non-graduate High School Grad / GED 12+ some post secondary 2 to 4 year College graduate
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
Disabling Condition?

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

Yes No
Physician, Address and Telephone Number
List Allergies (Food or Drug)
List Medications
Parent Information
Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Family Information
Housing

Own Rent Homeless Other permanent Housing
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
Participant's Waiver of Claim and Indemnity
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

Prevention Courses (Virtual Only)

Youth Services Program

Youth Information

Parent Information

Family Information

Participant's Waiver of Claim and Indemnity

Emergency Contact Information