WIOA Youth Program Eligibility Application

If you are receiving benefits,
please provide your case number:

Applicant Name:*

 (First, MI, Last)

Address:*

City:*

State:*

Zip:*

Phone Number:*

Alt Phone Number:

Additional Contact:

Contact Person's Phone Number:

Applicant Email Address*:

Driver's License?  Yes     No    Type:

Demographic Information

1. What is your date of birth?*   

2. What is your gender?   Male     Female

3. What is your ethnicity?   Hispanic/Latino     Not Hispanic/Latino    

4. What is your Race? (Check all that apply)
 Black/African American
 Asian
 American Indian
 Hawaiian Islander or Other Pacific Islander
 White
 Alaskan Native
  Other   

5. What is your native or primary language? 

6. If you are a male over 18 years old, have you registered for Selective Service?  Yes   SSR #:     No     N/A

7. Citizenship:
 US Citizen
 Documented
 Undocumented
 Refugee
 Other Legal Alien
  Other   

WIOA Eligibility Information

1. Have you been or are you a member of a family who received public cash assistance or SNAP in the last 6 months?  Yes     No

2. Do you have a disability?  Yes     No    ADA Major Life Activity Impairment    ADA and Employment Impairment

3. Are you pregnant?  Yes     No

4. Do you have any minor children?  Yes     No

5. If English is not your native or primary language, do you need help learning to speak/write/use English?  Yes     No

6. Are you homeless?  Yes     No

7. Are you a runaway?  Yes     No

8. Are you in foster care or were you previously in foster care?  Yes     No

9. Are you involved or were you involved in the juvenile court or adult justice system?  Yes     No

10. Do you receive or are you eligible to receive free or reduced price lunch?  Yes     No

Educational Information

1. What is your education level?
 Withdrew from high school, no HS diploma
 Current high/junior high school student
 Completed 12th grade, but no HS diploma
 Obtained GED or equivalent
 High school graduate
 Some post high school education, no degree
 College Degree:    Associate    Bachelor    Masters/Prof  

2. What is your education status?
 I am not a student
 I am a student at a college or technical school
 I am student in a GED program
 I am a high school student, at grade level
 I am a high school student, behind grade level
 I am not attending high school

Additional WIOA Intake Information

1. Do you need reliable child care?  Yes     No

2. Are you a single parent?  Yes     No

3. Do you have stable housing?  Yes     No

4. Do you use recreational drugs regularly?  Yes     No

5. Do you drink alcohol regularly?  Yes     No

6. Do you have reliable transportation?  Yes     No

7. Are you caring for an adult relative with a disability?  Yes     No

8. Do you need reliable dependent care?  Yes     No