Youthbuild 2016-17 Application

NAME *

First Name Last Name

DATE OF BIRTH *

Month Day Year

GENDER IDENTITY *

Are you authorized to work in the U.S. *

YES NO

ADDRESS *

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

E-MAIL

CELL PHONE

- Area Code Phone Number

HOME PHONE

- Area Code Phone Number

SECONDARY/EMERGENCY CONTACT INFORMATION:

Please provide information for someone other than yourself who we can contact if we need to get in touch with you and cannot reach you.

NAME *

First Name Last Name

RELATIONSHIP TO YOU *

ADDRESS *

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

CELL PHONE

- Area Code Phone Number

HOME PHONE

- Area Code Phone Number

E-MAIL

ELIGIBILITY REQUIREMENTS: SELECT YES or NO

Will you be between 16-24 years old on October 3, 2016? *

YES NO

Are you currently a Dutchess County resident? *

YES NO

Did you drop out of high school? *

YES NO

If yes, what grade?

Do you receive services from DCFS? *

YES NO

If yes, which program?

Family Assistance Medicaid Supplemental Nutrition Assistance Program HEAP SSI Plublic Housing

Because we reengage young people who have dropped out of school, the application process at YouthBuild Poughkeepsie has five essential steps:

Step 1: Complete this application and submit before the deadline of Monday September 26, 2016

Step 2: All applicants meeting the eligibility requirements will be scheduled to take the TABE (Test Of Adult Basic Education). You must take the test and score above the 5th grade level.

Step 3: All applicants who are contacted to continue the enrollment process must attend an information session. If you are under 18, you must attend the session with your parent or guardian. Information session dates will be posted on our website or will be sent to your email. You must attend the information session so we can tell you more about the program, answer questions and complete the interview assessment.

Step 4: All applicants who complete steps 1-3 will be invited to Pre-YouthBuild scheduled to start October 3, 2016. Upon successful completion, you will be invited to Mental Toughness Training, November 7 - 18, 2016. Students must attend all days of Pre-YouthBuild and Mental Toughness Training before you are enrolled in YouthBuild.

The deadline to submit this application is Monday September 26, 2016

Signature *

Date

/ Month / Day Year

ADDITIONAL INFORMATION:

How did you hear about YouthBuild? Check all that apply *

YouthBuild alumni YouthBuild current student YouthBuild staff member Family member or Friend Facebook Judge / justice system Radio SEPTA Other

Please remember:

 Contact (845) 452-8574 if your address or phone number changes during the application process.
 Regularly check your email inbox, spam folder, and “other” Facebook messages inbox for messages from YouthBuild.

We must have a way to contact you so that you know your application status and details about Mental Toughness.

NUBIAN DIRECTIONS YOUTHBUILD PARTNERSHIP 2016-2017 APPLICATION

PERSONAL CONTACT INFO