Workforce Alliance

Welcome to the Summer Youth Employment and Training Program 2009

Personal Information:
First Name: * MI: Last Name: * Suffix (Jr, Sr, III):
Social Security Number: --* Age: * Date of Birth: *‡ (use mm/dd/yyyy)
  ‡ You must be at least 18 and not have reached your 25th birthday at the time of enrollment into the program, June 15th, 2009.
Gender: Male Female
For Males, 18 years and older:
Have you registered for the selective service?		 Yes No
  If no, register immediately at http://www.sss.gov
Are you the child or eligible spouse of a Veteran? Yes No
Are you a U.S. Veteran? Yes No
Are a U.S. Citizen?
  If you are not a U.S. Citizen you must provide a work visa. If you cannot provide a work visa do not complete this application.

Address/Contact Information:
!! This is the address your packet will be mailed to if you are selected for the program. Incomplete or inaccurate information will prevent your packet from reaching you and result in disqualification. Example Address: 6201 N.W. 14th Ave. Apt. 3B
 
Address:
City: State: Zip:
Your Home Telephone Number: () -* Your Cell Phone Number: () -
Other Phone Number to Reach You: () - Email Address:
Verify Email Address:

Parent or Guardian's Contact Information:
(If you live at home or are a full time student living on or near a college campus during the school term)
 
Parent or Guardian's Name: Telephone Number: () -
Cell Phone: () - Other Contact: () -

Demographic Information:
Are you currently in school? Yes No
Education Level:
School you will attend September 2009:
Grade you are starting September 2009
Are you married? Yes No
Do you have children? Yes No How many?
Will you require daycare assistance? Yes No
Household Income
Race:
Ethnicity:
Country of Birth:
Language Spoken at Home:
Cultural Influence:
Total Number of Persons Living in Your Home?
Number of Adults Living in Your Home?
Number of Children Living in Your Home?

Employment Information:
Are you currently employed? Yes No
Current or most recent employer:
Supervisor's Name:
Address:
Phone: () -
Current or most recent rate of pay per hour:
Dates of employment: From: mm/dd/yyyy To: mm/dd/yyyy

Income Information:
Your Income for past six months:
(include your family your family income if claimed as a dependant and/or married):
Do you receive public assistance or have you received public assistance within the past six months? Yes No
If claimed as a dependent or if you are married, did you or your family receive public assistance within the past six months? Yes No

Work Information:
Worksite location preference (City):
How do you plan to get to work?
What hours are you able to work?
List any languages other than English you speak:
Available to work Monday-Friday? Yes No
Available to Work Saturday? Yes No
Available to Work Sunday? Yes No
What type of work would you prefer?
Select all that apply:
  Need assistance to secure and hold employment.
  Attending an alternative school or working toward a GED
  School dropout
  Homeless or runaway
  Foster Child
  Are you Pregnant?
  Possess one or more disabilities, including learning disability.
Have you been CONVICTED of ANY violation of the law, other than minor traffic offenses,
or pleaded NOLO CONTENDERE to criminal charges, even if adjudication was withheld?		 Yes No
Name of offense: Name of and location of court:
Disposition of case: Case Date:
NOTE: A conviction does not automatically mean you cannot be in the program. The nature of the offense, how long ago it occurred, relationship to the assignment and the requirement of the worksite employer are given consideration.
Organization you were referred by (if any):
 
  Please: Click the Submit button only ONCE.
  Make sure all your information is correct BEFORE you click Submit.