This application is usually completed by the applicant with the assistance of staff, if necessary, after the applicant has finished an information session and made a decision that he/she wants to and is able to enter the program. If he/she has completed a similar application requesting the same information for a government program as part of a certification process, the YouthBuild organization or sponsoring agency should attempt to acquire a copy of that application.

Date

Name *

Street Address

City, State, & Zip *

Email Address *

Phone *

Cell Phone

Social Security Number *

Date of Birth *

Current Living Status Living with family Living alone Living with friends Living in a homeless shelter Living in a halfway house living in a work release program Other

Married? Yes No

Children? Yes No *

Are You African-American Hispanic White-American Asian-American Native-American Other

High School Diploma Yes No *

Number of People in Household

Choose the closest to your yearly income amount for last calendar year: $0-$5000 1 $5001-$$10000 2 $10,001-$15,000 3 $15,001-$20,000 4 $20,001-$25,000 5 $25,001-$30,000 6 $30,001-$35,001 7 $35,001-$40,000 8 More than $40,000 9

Is English the main spoken language in your household? Yes No

How often does communicating in English cause problems at work or school? Usually Sometimes Seldom Never

How were you informed about this YouthBuild program? Friends TV/Radio City-wide newspaper Neighborhood flyers/newspaper Shelter Parole Office Neighbors Other

Why are you interested in being in this program?

If you are accepted in this program, you will attend classes 3 hours per day, Monday through Thursday, studying reading, writing and math to help you prepare for the GED and for the construction trades. What would you like to get out of this class?

Do you have any physical, medical or other health problems? Yes No

If yes, please describe

Are you supposed to wear eyeglasses? Yes No

Do you have Asthma? Yes No

Do you smoke? Yes No

If you smoke, can you limit your smoking to breaks and lunchtime? Yes No

Have you ever had a physical examination? Yes No

If yes, when was your last physical exam?

Education & Work History

Last school attended

Highest grade completed

Last year in school

If you did not complete high school or get your GED, why did you drop out?

Did you take any shop courses in school? Yes No

If yes, which ones?

Do you plan or hope to go to college? Yes No

Do you know how to drive? Yes No

Do you own a car? Yes No

Do you have a driver/operator’s license? Yes No

Do you have a chauffeur’s/commercial license? Yes No

Have you ever been in another training program? Yes No

If yes, when?(Dates)

Name and location of program

Did you complete the program? Yes No

Have you ever held a job before? Yes No

Name of company

Address of company

Dates you worked

What was the pay per week?

Job Title

What kind of work did you do?

Supervisor’s name and title

Why did you leave?

Are you currently working? Yes No Full-time Part-time

Current hourly wage

Number of hours a week(average)

Have you ever had any construction experience? Yes No

Was it paid experience? Yes No

Please describe this experience

What are you interested in doing for a career?

What types of jobs do you think are available in the field of construction?

U.S. military service Yes No

Please provide which branch, rank,discharge & dates

Have you ever been convicted of a crime? Yes No

If yes, please describe and include dates and status of case

If yes, are you on probation? Yes No

If yes, name and phone number of officer

Are you on parole? Yes No

If yes, name and phone number of officer

Thank you for your application we will contact your shortly.