Primetime Youth Application
Erie County Department of Social Services – Division of Youth Services
Youth Name
Date of Birth
-
Month
-
Day
Year
Date
Address
City
Zip Code
Does the youth receive Public Assistance, Medicaid, SNAP, HEAP or SSI?
Yes
No
If not in receipt of Public Assistance, Medicaid, SNAP, HEAP or SSI, is the combined gross income of the youth’s household below the maximum amount for their family size?
Yes
No
Submit Application
Should be Empty: