YouthBuild Application

BASIC INFORMATION NAME: DATE: ADDRESS: CITY: STATE: ZIP CODE: COUNTY: EMAIL ADDRESS: *PHONE NUMBER: ALTERNATE PHONE NUMBER: GUARDIAN NUMBER: CLOSEST RELATIVE NUMBER: MALE FEMALE BRITHDAY: AGE: Please provide clear, accurate, and honest information below. This information will be on record for your file. Circle all information that applies to you. ETHNICITY WHITE NATIVE AMERICAN STATE INFORMATION MARITAL STATUS: SINGLE Circle to all that apply: DISABLITY SINGLE PARENT OTHER Are you a parent? HEALTH BLACK HISPANIC PACIFIC ISLANDER ASIAN

MARRIED LEARNING DISABILITY PUBLIC ASSISTANCE DISPLACED HOMEMAKER TANF

Number of dependents?

What, if any, medical or health problems/limitations do you have? 1. Do you have asthma? 2. Do you have diabetes? 3. Are you supposed to wear eyeglasses? 4. Do you have a doctor? 5. Have you ever had a physical examination? 6. If yes, when was your last physical? 7. Are you capable of lifting over 40 pounds 8. Do you have medical insurance? 9. If YES, name of insurance provider? YES YES YES YES YES DATE: YES YES NO NO NO NO NO NO NO

EDUCATION Last grade completed? SCHOOL NAME: SCHOOL ADDRESS: CITY: Did anything give you trouble in school? Were you in a Special Education program? What type of program? Were you diagnosed with a learning disability?

Age you left school?

STATE: YES YES YES NO NO NO

ZIP CODE: If yes, please explain. Number of years? If yes, please explain.

If did not complete high school or get GED yet, not why?

College or Vocational Training Experience? (If Applicable) If yes, please explain?

YES

NO

TRANSPORTATION 1. How do you get around? CAR PUBLIC 2. Do you know how to drive? YES NO 3. Do you own or have the use of a car or motorcycle? YES NO 4. Do you have a Driver's/Operator's License? YES NO 5. Are there any reasons why you could not obtain car insurance or a driver's license? 6. Is the vehicle you drive insured? TRAINING & WORK HISTORY Have you ever been in any other training program(s)? If yes, please give name and location of programs(s): Date you attend listed program? CONSTRUCTION EXPERIENCE Have you had any construction experience? Was it paid experience? YES NO YES YES NO NO

YES

NO

PERSONAL EXPERIENCE Have you ever been convicted of a crime?

YES

NO

If yes, please explain:

Do you have any outstanding Traffic Violations, Criminal Fines, or Delinquent Fees? If yes, please list:

YES

NO

HOW DID YOU HEAR ABOUT GARFIED JUBILEE YOUTHBUILD? NEWSPAPER TV FORMER TRAINEE RADIO FLYER OTHER: 1. What are your hobbies or interest?

NAME

2. What kinds of things do you read regularly?

3. Why are you interested in being in this program?

4. What are you interested in doing for a career?

5. Classes include studying reading, writing and math skills you will apply in the construction trades and will help you earn your GED (if needed). What do you want to get out of these classes?

6. What types of jobs do you think are available in the field of construction? ADDITIONAL INFORMATION U.S. Military Service If yes, which branch? Rank

YES

NO

Honorable Discharge

YES

NO

Dates:

* = Primary Telephone Number