Youth Build Evansville CK Newsome Community Center 100 E. Walnut St., Room # 3 Evansville, IN 47713 812-428-8533 phone 812-428-8539 fax Program Application 2013 Application Checklist This checklist will be filled out by the YouthBuild staff, but please use it to make sure that you have completed all requirements. Part One Application Essay Part Two TABE Test Interview Drug Screen ALL Eligibility Documentation Part Three Orientation Acceptance/Rejection Letter Sent YouthBuild Evansville is an Equal Opportunity Employer. APPLICANT NAME: PHONE NUMBER: Date Completed Date Completed Mental Toughness Date Completed 1
Date Received: BACKGROUND INFORMATION Name: Social Security Number: Address: Apt. City: State: Telephone: Cell: Email: Birthday: Age: Gender (please circle): Male Female US Citizen (please circle): YES NO Who would you identify as an adult mentor (other than parent or guardian) in your life at this time? Personal Characteristics Please write 1 for Primary and 2 for Secondary: Ethnicity Asian American/Pacific Islander Black/African American Hispanic/Latin American Native American Caucasian Multiracial/Other Other: Primary Language English Spanish Marital Status Annual Household Income Never Married None Married $1- $10,000 Divorced $10,001 - $20,000 Separated $20,001 - $30,000 Widowed $30,000 - $40,000 $40,001 and above Type of Housing Disability Public Housing (Caldwell/Fulton) Definition: a physical or mental condition that substantially House/Apartment limits one or more of the major life activities of an individual Homeless (do you receive SSI or SSDI currently?) Homeless Shelter 1. Do you have a disability? YES NO Halfway House 2. If YES, please explain: Work Release Program 2
Group Home Other Personal History Are you a high school drop out? YES NO Do you have your high school diploma? YES NO Do you have your GED? YES NO Less than 6th Grade 6th 7th 8th Employed: Full Time Employed: Part Time Unemployed: Looking Other Highest Grade Completed 9th 10th 11th 12th Current Employment Status Date most recent job ended: Hourly wage: Hours worked per week: Did you have medical benefits through your last job? YES NO Don t Know Did you have vacation benefits through your last job? YES NO Don t Know Do you have construction experience? YES NO Don t Know Dependants and Public Assistance Do you live by yourself? YES NO Do you live with your parents or other relatives? YES NO Children Do you have children of your own? YES NO If YES, how many? If YES, do they live with you? If YES, what is your oldest child's birthday? IF YES, what is your youngest child's birthday? Do you have any other dependants? (do you financially support anyone else?) YES NO IF YES, how many other people? IF YES, what is their relationship to you? Public Assistance Do you receive public assistance? YES NO 3
Does someone in your house besides you receive public assistance? YES NO Are you a non- custodial parent of a child who receives Food Stamps/TANF? YES NO Are you a TANF recipient? YES NO Do you receive food stamps? YES NO Foster Care Are you a foster child? YES NO DON'T KNOW Have you aged out of foster care? YES NO DON'T KNOW Criminal Justice History Please answer the following questions honestly. Have you ever been arrested? YES NO DON'T KNOW Do you currently have a case pending? YES NO DON'T KNOW Have you ever been convicted of a misdemeanor? YES NO DON'T KNOW Have you ever been convicted of a felony? YES NO DON'T KNOW Have you ever been in a juvenile detention center? YES NO DON'T KNOW Have you ever been in an adult correctional facility? YES NO DON'T KNOW Have you ever been on probation? YES NO DON'T KNOW Have you ever been on parole? YES NO DON'T KNOW Have you ever lost your voting rights? YES NO DON'T KNOW Substance Abuse History Please answer the following questions honestly. Are you routinely using any of these substances? Alcohol YES NO Marijuana YES NO Cocaine YES NO Heroine YES NO Other illegal substances YES NO Do you have a history of alcohol abuse? YES NO Are you currently undergoing substance abuse treatment? YES NO How did you hear about YouthBuild Evansville? Probation Officer parole officer Rehab facility Facebook Advertisement Website A friend Other: A family member 4
Essay Please write a ONE page essay on ONE of the following topics: 1 What is on the minds of America's youth today? 2 Why do you believe that YouthBuild is the right program for you? 3 Having a clear and realistic career goal is an important aspect of the YouthBuild Evansville Program. Please explain your career goal and the steps you would like to take while at YouthBuild Evansville in order to achieve that goal. Essay Number: 1 2 3 5
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