Name
*
First Name
Middle Initial
Last Name
SECTION I - PERSONAL INFORMATION
Gender
*
Male
Female
Non-binary/Other
Date of Birth:
*
-
Month
-
Day
Year
Date
Current Address:
*
City, State, Zip Code:
*
County of Residence:
*
E-mail Address:
*
example@example.com
Home Phone:
*
Format: (000) 000-0000.
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Cell Phone:
Format: (000) 000-0000.
Race/Ethnicity: (Select all that apply)
*
American Indian or Alaskan Native
Asian
Black or African American
Hispanic/Latino
Native Hawaiian or Pacific Islander
White
Other
Marital Status:
*
Married
Single
Divorced
Widowed
Separated
Domestic Partner
Monthly Household Income:
Primary Language Spoken at Home:
*
Number of Children:
*
Do your children reside with you?
Yes
No
Are you required to pay child support?
*
Yes
No
Are you a U.S. Citizen?
*
Yes
No
Are you authorized to work in the U.S. (If No to U.S. Citizen)?
*
Yes
No
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Additional Status Information
Do you possess a valid driver's license?
*
Yes
No
Are you registered to vote?
*
Yes
No
Have you registered with Selective Service? (Males 18+)
*
Yes
No
Do you have internet access at home?
*
Yes
No
Technology Access at Home (e.g., Computer, Tablet, Smartphone, etc.):
*
Current Living Situation: (Select all that apply)
Current Living Situation:
*
With parent/guardian
With spouse and/or children
Alone
With friends
In a homeless shelter
In a work/release program
Other
Foster Care History
*
Yes
No
Parental Incarceration History
*
Yes
No
Criminal Background Information
Have you ever been convicted of a crime? (Please answer honestly; this will NOT automatically exclude you from YouthBuild):
*
Yes
No
If Yes, please describe the charge, the date, and the current status of the case (Attach additional documentation if necessary):
Do you have any active court cases?
*
Yes
No
If Yes, please list the charge:
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Are you currently on probation and/or parole?
*
Yes
No
If Yes, please list the name and telephone number of your probation and/or parole officer:
Potential Barriers to Attendance
Do you anticipate any barriers (e.g., transportation, childcare, etc.) that could impact your consistent, timely attendance?
*
Yes
No
If Yes, please identify any such barriers (YouthBuild may be able to provide or refer you to necessary support):
SECTION II - EDUCATIONAL BACKGROUND INFORMATION
Last School Attended:
Name, City, and State of the last school attended:
*
Dates Attended:
(MM/YYYY - MM/YYYY)
From
*
MM/YYYY
To
*
MM/YYYY
Highest Grade Completed:
*
Special Education Services
*
Yes
No
Individualized Education Program (IEP)
*
Yes
No
High School Dropout Information
Please explain the reason(s) for dropping out of high school:
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GED Program Status
Are you currently enrolled in a GED program?
*
Yes
No
If Yes, which program?
Post-Secondary Education/Training Goals
Do you intend to pursue further education or training after completing your high school equivalency or graduation?
*
Yes
No
Not sure
If Yes, please select the intended type of program: (Select all that apply)
6 to 8 months training certificate
2-year college degree (Associate's)
4-year college degree (Bachelor's)
Graduate degree
Military service
Have you had Vocational / Construction Education Classes?
*
Yes
No
Have you had Machine Shop Classes?
*
Yes
No
Have you participated in training programs?
*
Yes
No
Did you complete training programs?
Yes
No
SECTION III - JOB TRAINING AND WORK EXPERIENCE
If Yes to Vocational or Construction Education, please describe the location and dates:
If Yes to Machine Shop Classes, please describe the location and dates:
If Yes to Training Program(s), please describe the location and dates:
If No to completing Training Programs, please provide an explanation:
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SECTION IV - EMPLOYMENT HISTORY
Have you ever been employed?
*
Yes
No
Most Recent Employment
Most Recent Employment
Rows
Job Title:
Start Date:
End Date:
1
Job Duties Description:
Employer Name:
Employer Phone Number:
Format: (000) 000-0000.
Average Hours Worked Per Week:
Hourly Wage:
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Reason for Leaving:
Supervisor Name:
May we contact this employer as a reference?
Yes
No
Previous Employment (If Applicable)
Previous Employment (If Applicable)
Rows
Job Title:
Start Date:
End Date:
1
Job Duties Description:
Employer Name:
Employer Phone Number:
Format: (000) 000-0000.
Average Hours Worked Per Week:
Hourly Wage:
Reason for Leaving:
Supervisor Name:
May we contact this employer as a reference?
Yes
No
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Do you have experience with Plumbing?
*
Yes
No
Do you have experience with Lift Truck?
*
Yes
No
Do you have experience with Electrical Wiring?
*
Yes
No
Do you have experience with Painting?
*
Yes
No
Do you have experience with Sheet Metal?
*
Yes
No
Do you have experience with Rough Carpentry?
*
Yes
No
Do you have experience with Roofing?
*
Yes
No
Do you have experience with Finish Carpentry?
*
Yes
NO
Do you have experience with Dry Wall?
*
Yes
No
Do you have experience with Finish Carpentry?
*
Yes
No
Do you have experience with Power Tools?
*
Yes
No
Do you have experience with Housing Rehabilitation
*
Yes
No
Do you have experience with Personal Computers?
*
Yes
No
Do you have experience with MS Word?
*
Yes
No
Do you have experience with Excel?
*
Yes
No
Do you have experience with Power Point?
*
Yes
No
Do you have experience with Web Design?
*
Yes
No
Do you have experience with CAD Equipment?
*
Yes
No
Construction and Computer Skills Assessment: Computer Proficiency
I am:
*
An expert - Proficient in running various applications, web navigation and advanced tasks
Intermediate - Capable of document creation and managing basic email communication
A Novice - Minimal or no prior computer usage experience
List any other tools or heavy equipment you have successfully operated:
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SECTION V - PHYSICAL AND HEALTH INFORMATION
Do you have any physical, medical, or other health conditions (including allergies) that could impact your ability to safely perform the physical activities required for construction work?
*
Yes
No
Do you have Health Insurance / Medicaid?
*
Yes
No
Do you have a Medical Marijuana Card?
*
Yes
No
Do you have a Fear of Heights?
*
Yes
No
Do you have a Asthma?
*
Yes
No
If 'Yes', please describe the condition(s) and potential impact:
Date of most recent physical examination?
-
Month
-
Day
Year
Date
Do you have a Diabetes?
*
Yes
No
Are you able to Bend, Stoop & Stand?
*
Yes
No
Do you have Heart-Related Issues?
*
Yes
No
Do you have Physical Limitations / Restrictions?
*
Yes
No
Do you smoke?
*
Yes
No
Have you had Recent Surgery?
*
Yes
No
Do you have lifting restrictions?
*
Yes
No
Do you have allergies?
*
Yes
No
Are you required to wear Eyeglasses / Contact Lenses?
*
Yes
No
If you answered "Yes" to any of the above health-related questions, please provide a detailed description:
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CSO
YOUTHBUILD
SECTION VI - PERSONAL STATEMENTS
INSTRUCTIONS: Your thoughtful and complete responses to the following questions are
mandatory and must be submitted with your application. YouthBuild is a challenging program
designed to support and facilitate the transformation of your life and future.
1. How did you hear about YouthBuild?
*
2. Explain why you want to participate in YouthBuild.
*
3. What are you good at?
*
4. What goal (for your life, future, family, etc.) will you use to stay motivated, and give your best effort through the program successfully?
*
5. How will you get to YouthBuild each day?
*
6. Please describe your experiences working outdoors
*
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