WIOA Youth Participant Interest Form
Date
-
Day
-
Month
Year
Date
Name
First Name
Last Name
City
State
County
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Gender
Male
Female
Age (Must be 16-24)
Are you currently enrolled in school (High School or College)
Yes
No
If you answered no to the above question, what year did you graduate/drop out of school?
WIOA Barriers (Check all that apply to you, this determines WIOA eligiblity)
High School Dropout
Ex Offender/Convicted of a crime (including tickets)
Homeless
Foster Care (At any point in life)
Pregnant/Parenting
Disability/IEP In High School
Low Income and English Language Learner
Low Income and Basic Skills Deficient (TABE Scores Required)
None of the above
Are you receiving SNAP/EBT/TANF?
Yes
No
How many individuals live in your household? (including yourself)
Registered with the Selective Service (18 Y.O. Males Only)
Yes
No
What field/type of work are you interested in?
Do you have a driver's license?
Yes
No
Do you have reliable transportation?
Yes
No
This interest form and the WIOA Youth programs described is 100% supported by a federal U.S. Department of Labor Employment and Training Administration Workforce Innovation and Opportunity Act (WIOA) award of $355,155 (AA-34799-20-55-A-51) made to Charlotte County on behalf of the South Central Workforce Development Area by the pass-through entity, the Virginia Community College System. No costs of this program are financed by nongovernmental sources. "The South Central Workforce Development Board is an Equal Opportunity Employer/Program: Auxiliary aids and services are available upon request to individuals with disabilities." VA Relay 711
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