Lifescore Youth Employment Application

CONTACT INFORMATION
Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live in Illinois?*

YesNo
Are you authorized to work in the US?*

YesNo
Are you currently in school (when school is in session)?*

YesNo
Do you have a high school diploma or equivalent?*

YesNo
Select one or more that apply to you*

I do not have work experience.I have been fired or forced to quit one or more jobsNo one in my household is employed.I or my immediate family receive TANF BenefitsI or my immediate family receive SNAP benefitsI would be eligible to receive Free/Reduced lunch at school when I attend school.I live in a single-parent household.I am homeless, (includes couch surfing)I have had or I am currently involved with DCFS – Dept of Children & Family ServicesI have a brother/sister who is a teen parentI am pregnant.I am a parent of one or more childrenI identify as LGBTQ or non-binary.I have a disability.I have an Individual Education Plan (IEP) at schoolI often have a hard time with my school workI have been held back one or more grades at school OR My teacher says I am in danger of being held backOver the past year, I have skipped school several timesI am or have been expelled or suspended from high schoolI dropped out of high school / I did not graduateI have a brother/sister who dropped out of school.Over the past year, I have been in trouble for my behaviorI have been a victim of bullying.I have been called a bully by othersI am under age 18 and regularly left unsupervised after schoolMy home is dysfunctional due to mental health or substance use.I have been and/or I have seen someone in my family suffer mental or physical abuse in our home.I have had a friend or a family member die from gun violenceI live in a community where it is not safe because of crime and/or gun violenceI have a parent(s) who have been or is currently in jail/prisonI have a sibling who has been or is currently in jail/prison.I have been arrested one or more times in the past.I have been held one or more days in jail, prison, or a detention centerI have a parent or sibling who has been or is currently a member of a gang.I am in a gang.None of the above
Gender*

MaleFemaleNon-binaryPrefer Not to Answer
Military Status*

NoneActiveVeteranDischarged
Marital Status*

SingleMarriedDivorcedOther
Ethnicity*

Non-Hispanic or LatinoHispanic or Latino
Race*

WhiteAsianHawaiian or Pacific IslanderBlack/African AmericanAmerican Indian or Alaskan NativePrefer Not to Answer
Primary Language*

EnglishArabicCambodianCantoneseChineseFrenchGermanJapaneseKoreanOtherFilipinoPolishRussianSign LanguageSpanishVietnameseItalian
Secondary Language*

EnglishArabicCambodianCantoneseChineseFrenchGermanJapaneseKoreanOtherFilipinoPolishRussianSign LanguageSpanishVietnameseNoneItalian
PROVIDER
Select a Provider*

DHS - Lifescore
EMPLOYMENT GOALS
What are your immediate employment goals?*

Find full-time employmentFind part-time employment
How can you travel to training?*

Bus (Public Transportation)Train (Public Transportation)DrivingWalkBicycle/ScooterDropped Off by Other
When are you able to work?*

DayEveningNightWeekendsOther
See yourself in 1 year: *
See yourself in 5 years: *
What steps have you taken to get there?*

Researched Careers, Wages, and TrendsResearched Training ProvidersStarted/Completed Some TrainingResearched/Applied for Financial Aid/ScholarshipsStarted or Completed a ResumePrepared for an InterviewCreated a PortfolioApplied for JobsUpdated Online Persona to Align With Your GoalsJoin Student/Trade Organization or Follow Their Social MediaNetwork With Others in Your Field of InterestNetwork With Others to Find a JobNo Actions TakenOther
What do you see as your work-related skills or strengths? Include knowledge of operating machines and equipment, ability to type, tools owned, etc. *
PHYSICAL DEMANDS
What is the heaviest load that you can lift in the workplace?*

55 pounds50 pounds (a bale of hay = 50 pounds)30-40 pounds (5 gallons of water = 40 pounds)25 pounds (an average 2 year old = 25 pounds)Less than 25 pounds
What is the longest amount of time that you could stand upright in the workplace?*

8 hours6 hours4 hours2 hoursLess than 2 hours
Are you able to pass a drug test?*

Yes, I'm drug-free and can pass a drug testYes, I have been drug-free for at least 30 daysYes, I am willing to make changes to be able to pass a drug testYes, I want to be able to pass a drug test, but I need helpI am not interested in careers that require a drug test
Describe your eyesight or vision*

I can see without glasses or contactsI can see with glasses or contactsI am legally blind
What work environment do you prefer?*

ClericalConstructionCustomer ServiceFood ServiceGrounds Keeper/GardenerHousekeepingHealth Services (e.g. Pharmacy Tech)Mechanical (e.g. Auto Tech/Manufacturing)MaintenanceOther
OTHER ITEMS
Do you have a valid drivers license?*

YesNo, but I could get a drivers license if I had trainingNo, I am not able to get a drivers licenseMy license is temporarily suspended
Some employers will complete a background check on new employees. Please check all of the following that apply.*

I am registered on the sex offender registryI have a violent felony convictionI have a non-violent felony convictionI have a misdemeanor conviction (excluding traffic violations) within the past 7 yearsI have been on probation in the last 10 years (excluding traffic violations)I am not interested in careers that require a background checkNone of the above apply to me
EDUCATION LEVEL
Highest Level of Education:*

SelectNone1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeH.S. FreshmanH.S. SophomoreH.S. JuniorH.S. Senior - Did not Receive H.S. Diplomav H.S. Senior - Received H.S. DiplomaGEDCol. FreshmanCol. SophomoreCol. JuniorAssociate DegreeBachelor's DegreeMastersDoctorateNot ReportedReceived Certificate of Attendance/CompletionReceived Other Post-Secondary Degree or Certificate
Do you have more degrees, certificates, licenses, or credentials?*

YesNo
EMPLOYMENT HISTORY
Employment Status:*

SelectEmployedNot In Labor ForceUnemployedEmployed But Received Notice Of Termination
Have you had a job?*

YesNo
FINAL QUESTIONS
Are you working with any of the service providers below?*

Center for Independent LivingCommunity CollegeIllinois Department of Employment Security (IDES)Illinois Department of Healthcare and Family ServicesIllinois Department of Human Services Office of Mental Health & Developmental DisabilitiesIllinois Department of Human Services Office of Vocational RehabilitationIllinois Division of Rehabilitation Services (IDRS)National Association of Mental Illness (NAMI)Special Education DistrictVeterans AdministrationN/AOther IDHS Program
How did you hear about this program/Illinois WorkNet?*

EmailFacebookFamily or FriendsLocal DHS OfficeIllinois workNet CenterIllinois workNet WebsiteLinkedInMailingsNewspaper or MagazineRadioTVTwitterOther
Resume and Files

Cancelof
References

Please list one (1) references that are familiar with your work life.
Reference
By signing below, I confirm that all information provided in this application is true and accurate to the best of my knowledge. I understand that any false statements or deliberate omissions may disqualify me from consideration for employment or result in termination if discovered after hiring. I also acknowledge that this application does not guarantee employment.I have reviewed my availability as stated above and commit to maintaining this availability should I be selected for employment, understanding that consistent availability is crucial to my success in the program.

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CONTACT INFORMATION

PROVIDER

EMPLOYMENT GOALS

PHYSICAL DEMANDS

OTHER ITEMS

EDUCATION LEVEL

EMPLOYMENT HISTORY

FINAL QUESTIONS