YBL Student Application Form

YouthBuild Louisville: Student Application

YouthBuild Louisville is dedicated to providing the most comprehensive service for each participant, and in order to ensure YouthBuild’s ability to best serve you, the following form must be completed thoroughly. Please fill out each item as directed.
Name: *

First Name Middle Name Last Name
Nickname
Age *
Birth Date *

Month Day Year
Phone Number: *

Area Code Phone Number
Other Number:

Area Code Phone Number
E-mail Address: *

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Education:
Last School Attended: *
Do you have your High School Diploma? (HSD) *

Yes No
If not, what was the highest grade you completed? *
Number of years out of school? *
Do you have your GED? *

Yes No
Eligibility
Gender *

Male Female
US Citizen Status *

Yes No
Authorized to work in the US? *

Yes No
Registered to Vote? *

Yes No
Do you have your Driver's License? *

Yes No
Registered for Selective Service? (NOTE: If you are Male and 18 years old, you MUST be registered. We will help you complete this process.) *

Yes No Not Applicable (Female or under 18)
Employment Status as of today: *

Employed Full Time Employed Part Time Unemployed (Actively Looking) Unemployed (Not Looking)
Race *

Asian White Native or other Pacific Islander Black or African American American Indian or Alaskan Hawaiian Other
Marital Status: *

Single Married Domestic Partner Divorced
Household Income: *

None $1 - $10,000 $10,001 - $20,000 $20,001 - $30,000 $30,001 - and above Other
Public Assistance (Indicate ALL that apply as of today) *

No Benefits SSI TANF/K-TAP Public Assistance/ Non-TANF Unemployment Insurance Food Stamps (SNAP) Public Housing
Check all that apply to you: *

Low-income family Migrant Youth Youth in Foster Care Aged out of Foster Care Youth Offender Child of Incarcerated Parent Immigrant Homeless Veteran Have Documented Disability
How did you hear about YouthBuild Louisville? *

Referred by Guidance Counselor Referred by Case Manager Referred by Probation/ Parole Officer Referred by Friend/ Colleague/ Relative Advertisement/ Flyer
Name of referring person:
Fields of Interest: *

Construction Trade Nursing Assistant Urban Conservation Culinary None of the above
Job Skills & Training
Do you have a resume? If so, upload it below. Do you have other skills you would like to tell us about? Have you attended any trainings or have any certifications you would like us to know about? If so, list those in the appropriate areas below.
Describe your skills:
Training or Certifications:
Signature

I HEREBY CERTIFY THAT THE ANSWERS GIVEN BY ME ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER CERTIFY THAT I, THE UNDERSIGNED APPLICANT, HAVE PERSONALLY COMPLETED THIS APPLICATION. I VERIFY BY MY SIGNATURE THAT THE ABOVE ADDRESS IS MY CORRECT LIVING ADDRESS. I HEREBY AUTHORIZE YOUTHBUILD LOUISVILLE TO THOROUGHLY INVESTIGATE MY WORK RECORD, EDUCATION AND OTHER MATTERS RELATED TO MY SUITABILITY FOR ACCEPTANCE INTO THE PROGRAM. PLEASE ENTER YOUR INITIALS IN THE SPACE BELOW, INDICATING YOUR AGREEMENT TO THE TERMS LISTED ABOVE. YOUR INITIALS IN THE SPACE BELOW ACT AS YOUR SIGNATURE TO THIS DOCUMENT.
INITIALS *
Should be Empty:

YouthBuild Louisville: Student Application

Education:

Eligibility

Job Skills & Training

Signature