YOUTH WORKFORCE INNOVATION & OPPORTUNITY ACT (WIOA APPLICATION)

Application Date *

Name *

First

Middle

Last

Social Security Number *

Phone *

Alternate Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Emergency Contact Name *

First

Last

Relationship *

Emergency Contact Phone *

Emergency Contact Address *

Address Line 1

Address Line 2

City

State

Zip Code

Demographic Information

Date of Birth *

Age *

Arte you registered for Selective Service (Males Only)

Yes
No

Authorization to work in the U.S. *

Race/Ethnicity *

If other race/ethnicity (Please Specify)

Are you considered to be of Hispanic Heritage? *

Yes
No

Are you considered to have a disability? *

Yes
No
Participant did not self-identify

If “No” or Participant did not self-identify, skip to Transitioning Service Member

Select disability verification document

If other disability document, please specify:

Did you have an IEP in school? *

Yes
No

Did you have a Section 504 Plan?

Yes
No

Category of Disability *

Have you received services from Vocational Rehabilitation? *

Yes
No

Employment Status *

Family Size *

Total Household Income *

Public Assistance

(Individual or member of a family that is receiving, or in the past 6 months has received the following:

Are you receiving TANF *

Yes
No

Are you receiving Supplemental Security Income (ISS) *

Yes
No

Are you receiving Refugee Cash Assistance (RCA) *

Yes
No

Are you in a household receiving Food Stamps (SNAP) *

Yes
No

Are you receiving or have you been notified you will be receiving the Pell Grant? *

Yes
No

Are you a Foster Child? *

Yes
No

Are you a youth living in a high poverty area? *

Yes
No

Are you a youth who currently receives, or is eligible to receive, free or reduced lunch under the Richard B. Russell National School Lunch Act? *

Yes
No

What are your future goals?

Short Term (Less than a year) and Long Term (More than one year)

Education (Short Term) *

Education (Long Term) *

Employment (Short Term) *

Employment (Long Term) *

Personal Goals (Short Term) *

Personal Goals (Long Term) *

Dream Career 1

Dream Career 2

Dream Career 3

Individual Barriers

English Language Learner *

Yes
No

Basic Skills Deficient/Low Levels of Literacy *

Yes
No

Are you homeless? *

Yes
No

Are you a runaway? *

Yes
No

Are you a youth in, or aged out of Foster Care? *

Yes
No

Are you an ex-offender? *

Yes
No

Have you been convicted of a:

Felony
Misdemeanor
Awaiting Court Decision
Does not apply

Are you pregnant or a parenting youth? *

Yes
No

Do you require additional assistance to complete an educational program or to secure/hold employment? *

Yes
No

Out of home placement? *

Yes
No

Are you eligible under Section 477 of the Social Security Act? *

Yes
No

Employment History

List current and previous employers for the past 10 years starting with your most recent employer

Most Recent Employer

If none, type N/A

Type of Business

Retail, Manufacturing, Health Care, Construction, etc.

Work Address

Address Line 1

Address Line 2

City

State

Zip Code

Work Phone

Job Title

Job Type

Paid
Volunteer
Internship

Hourly Wage

Hours per week

Main Duties

Equipment Used

Start Date

End Date

Reason for leaving

Other* reason for leaving

Employer 2 Information

Previous Employer

If none, type N/A

Type of Business Employer 2

Retail, Manufacturing, Health Care, Construction, etc.

Employer 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title Employer 2

Job Type Employer 2

Paid
Volunteer
Internship

Hourly Wage Employer 2

Hours per week Employer 2

Main Duties Employer 2

Equipment Used Employer 2

Start Date Employer 2

End Date Employer 2

Reason for leaving employer 2

Other* reason for leaving employer 2

Employer 3 Information

Employer 3

If none, type N/A

Type of Business Employer 3

Retail, Manufacturing, Health Care, Construction, etc.

Employer 3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title Employer 3

Job Type Employer 3

Paid
Volunteer
Internship

Hourly Wage Employer 3

Hours per week Employer 3

Main Duties Employer 3

Equipment Used Employer 3

Start Date Employer 3

End Date Employer 3

Reason for leaving employer 3

Other* reason for leaving employer 3

Education Goals

Employment Goals *

Educational Goals *

Are you currently enrolled in a GED Program *

Yes
No

Have you passed any part of the GED *

Yes
No
Does not apply

If yes, which part of the GED test did you pass

Science
Math
Language Arts
Social Studies

Highest Level of education I have completed is *

Choose the grade level or years of college

List the name(s) of other schools attended, include degrees/certificates and area of study

School 1

Course of Study 1

Did you graduate from school #1?

Yes
No

Year of graduation from school 1

School 2

Course of Study 2

Did you graduate from school #2?

Yes
No

Year of graduation from school 2

School 3

Course of Study 3

Did you graduate from school #3?

Yes
No

Year of graduation from school 3

Are you receiving services from Adult Education (WIOA Title II)? *

Yes
No
Did not self identify

Are you receiving services from YouthBuild? *

Yes
No
Did not self identify

Are you receiving services from Job Corps? *

Yes
No
Did not self identify

Are you receiving services from Vocational Education (Carl Perkins)? *

Yes
No
Did not self identify

Are you an Individualized Education Program Participant *

Yes
No
Did not self identify

I hereby affirm that the information provided on this application is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for WIOA program activities and may be considered justification for dismissal if discovered at a later date. I acknowledge that my Personal Identifying Information (PII) will be used fro grant purposes only. I also agree to obtainining signatures to affirm information on this document and Medical and Disability Release Form sent to me separately. *

I affirm the information is true