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YouthBuild Interest Form
Please fill out all information to the best of your ability
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Where did you hear about this program?
Facebook
Twitter
Reddit
Flyer
Friend/YB Staff member
Other:
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Name:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Place of Birth (City, State, County)
*
Your answer
Gender
*
Male
Female
Nonbinary
Address (Street, City, State, ZIP)
*
Your answer
Mailing Address (if different from above)
Your answer
Primary Phone
*
Your answer
Secondary Phone
Your answer
Email address
*
Your answer
County of Residence
*
Wyandotte
Jackson
Johnson
Clay
Other
Relationship Status
*
Married
Single
Divorced
Seperated
Co-habitating/Domestic partnership
Emergency Contact Name and Phone Number
*
Your answer
Race (check all that apply)
Black
Hispanic (non-white)
Indian Subcontinent
Indigenous American
Caucasian/White
Asian
Hawaiian Native/Pacific Islander
Other:
Are you a U.S Citizen
*
Yes
No
If No, are you eligible to work in the United States?
Yes
No
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Do you have on hand a copy of your birth certificate, Social Security card, and state issued ID? You will need these to enroll, so if you don't currently have them, you should start gathering them now.
*
Yes
No
I have some, but not all
If English is not your native language, what is?
Spanish
Other:
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Check any boxes that you may want help with
*
Educational Counseling
Work Experience
Child care assistance
Family Counseling
Mental Health Counseling
Occupational Skills Training
Job Readiness Training
Skill Upgrade/Retraining
Internships
Adult Mentoring
Leadership Development
Entrepreneurial Training
Alcohol/Drug Counseling
Other:
Required
Check any challenges you are experiencing
*
TANF Exhaustee
Pregnancy
Parenting Teen/Young Parent
Domestic Violence
Homelessness
Learning Disability
Parents receiving welfare
Poor Work History
Foster Youth
Gang Affilliation
Transportation Issues
Parental incacertion
Difficulty obtaining employment/ongoing education
Other:
Required
Name of high school and year graduated
*
Your answer
Tell us why you are interested in our program!
*
Your answer
Is there anything else you would like to tell us about yourself?
Your answer
Did you attend one of our online Zoom informational sessions?
*
Yes
No
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