Youthbuild 2016-17 Application

NUBIAN DIRECTIONS YOUTHBUILD PARTNERSHIP 2017-2018 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

PERSONAL CONTACT INFO
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
The following are requirements to be a YouthBuild student:

(1) Applicant must be between the ages of 17-24 years old as of October 2, 2017;

(2) Applicant must be a resident of Dutchess County and have proof of address.

(3) Applicant must be a high school dropout or not on track to earn their high school diploma or has their high school diploma/HSE already.
Will you be between 17-24 years old on October 2, 2017? *

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(SNAP) 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 FRIDAY September 15, 2017

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 and Mental Toughness Training. You will be notified of the schedule. 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 15, 2017
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.
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NUBIAN DIRECTIONS YOUTHBUILD PARTNERSHIP 2017-2018 APPLICATION

PERSONAL CONTACT INFO