OhioMeansJobs Warren County Youth Program Interest Form

OhioMeansJobs Warren County Youth Program Interest Form
Name of Youth*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender assigned at birth:*

MaleFemalePrefer not to answer
Emergency Contact*

NamePhone Number
What is your ethnicity?*

LatinoNot LatinoPrefer not to answer
Citizenship (check all that apply):*

US CitizenRegistered AlienRefugeeOther Legal AlienOther
What is your race? (check all that apply)*

Black/African AmericanAsianAmerican Indian/Alaska NativeHawaiian Islander/Other Pacific IslanderWhiteOther
Are you legally restricted from using a computer?*

YesNo
Relationship Disclosure - Do you have a business or personal relationship with any individual who is a: Local elected official (mayor or county commissioner); Workforce Development Board member or subcommittee member; WIOA executive, supervisor or employee;OhioMeansJobs center partner employee, WIOA sub-recipient and/or contractor; or County employee?*

YesNo
What is your education level:*

Current high/junior high school studentWithdrew from high school, no HS diplomaCompleted 12th grade, but no HS diplomaObtained certificate of equivalency for HS diplomaHigh School graduateSome post high school education, no degreeCollege degree
Do you have work experience in Agriculture within the last 12 months?*

YesNo
What is your current education status?*

I am not a studentI am a student at a college or technical schoolI am a student in a HS equivalency programI am a high school student, at grade levelI am a high school student, behind grade level
If attending school, which school do you currently attend?
Have you served in the US Military?*

YesNo
Are you a spouse of a veteran?*

YesNo
Are you a homeless veteran?*

YesNo
Do you hold a valid drivers license?*

YesNo
Are you interested in an Apprenticeship?*

YesNo
Have you registered for Selective Service (for individuals born male, 18 or older)?*

YesNoExemptUnsure
Are you enrolled in ASPIRE?*

YesNo
Have you received OWF for one or more years?*

YesNoUnsure
Have you taken a recent math/reading assessment?*

YesNo
Do you use recreational drugs or drink regularly?*

YesNo
Are you a single parent?*

YesNo
What is your native or primary language?*
Do you think you have a cultural barrier that might hinder employment?*

YesNo
Are you homeless?*

YesNo
Are you a public assistance recipient (cash/food)?*

YesNo
Are you enrolled in Vocational Rehab through OOD?*

YesNo
Are you receiving SNAP Employment and Training?*

YesNo
Do you have a disability?*

YesNo
Are you a runaway?*

YesNo
If English is not your native or primary language, do you need help learning to speak/write/use English?*

YesNo
Are you involved or were you involved in the juvenile court or adult justice system?*

YesNo
Are you in foster care or were you previously in foster care?*

YesNo
Are you pregnant?*

YesNo
Are you a parent (including noncustodial)?*

YesNo
Are you/have you received a Pell Grant?*

YesNo
Is your family eligible to receive free/reduced-price lunch?*

YesNo

If you are an in-school youth (i.e. attending high school or a post-secondary program), do not complete this section if you are homeless, a runaway, or a foster youth. If you are not attending school, only complete if your case manager requests you to do so. Please answer the following questions if you are 18 or older:*

	Yes	No
Do you provide more than 50% of your own support?
Are you married or separated but not divorced?
Do you have children who receive more than half of their support from you?
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?
Do you have your own residence or in a residence without support from a parent(s) or a guardian(s)?
Have you been, or are you a member of, a family who received public cash or food assistance in the last 6 months?

If you answered "yes" to any questions directly above, you are independent of a parent or guardian and only your income will be used to determine WIOA youth eligibility.

Only complete the next section if you are attending school (high school or college/technical school) or your case manager asks you to. Including yourself, who is in your household? What is their relationship to you? What is their average monthly income? (Your case manager can let you know the timeframe to consider.) If you have a disability, only include your personal income.

	Name	Age	Relationship	Hourly Wage	Average Monthly Income
1.
2.
3.
4.
5.
6.
7.
8.

Have you or anyone you are living with been ordered to repay cash assistance (OWF), due to determination of fraud and still owe repayment?*

YesNo
Are you currently receiving cash assistance?*

YesNo
Are you currently receiving SNAP?*

YesNo

Complete the table below indicating each household member's monthly income:

	Name	Relationship	Hourly Wage	Monthly Income
1.
2.
3.
4.
5.
6.
7.
8.

Do you have a child under age 18 or is 18 who is attending high school full-time?*

YesNo
Are you one of the following (check all that apply):*

A parent, specified relative, legal guardian or legal custodian of a minor childA non-custodial parentA pregnant individualA minor child (including age 18 attending high school full-timeAn individual age 18-24 that is part of a family that includes a minor child?None
Have you been given the opportunity to register to vote?*

YesNoN/A (age 16 or under)
What do you hope to achieve through your participation in a CCMEP youth program?*
By signing, I attest that the information stated on this application is true and accurate. I understand that if the information or income provided was misrepresented, it may be grounds for immediate termination in the CCMEP program and/or penalties as specified by law. If the applicant is under age 18, the parent/guardian signature below gives permission for the youth to participate in CCMEP services and activities. Parent/Guardian Signature (if applicant is under age 18):*

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Applicant signature*

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