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Pre-application for CPLC's WIOA Youth Program for Phoenix and Metro Areas
(*Maximum age:
In-school 21 years
,
Out-of-school 24 years)
Each part of the pre-application must be filled accurately. Incomplete applications will not be processed.
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
How did you hear about Chicanos Por La Causa's WIOA youth program?
If you heard from a friend or organization, please provide the full name.
*
Your answer
What is your first and last name?
*
Your answer
Date of Birth MM/DD/YYYY
*
MM
/
DD
/
YYYY
Age
*
Your answer
Street Address
*
Your answer
Apartment Number
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Gender
*
Male
Female
Prefer not to say
Other:
I am a
*
U.S. Citizen
Permanent Resident
DACA
Refugee
Other:
What is your native language?
*
Your answer
Are you an English Language Learner?
*
Yes
No
What other languages do you speak?
*
Your answer
Where do you currently live?
*
Self
Friend/s
In Foster Care
Group home
With parent/s or family member/s
Homeless
Other:
Number of people in your household? Include yourself.
*
Your answer
Total "monthly income" of all working individuals in your household including yourself:
*
Your answer
Are you pregnant or parenting?
*
Yes
No
Do you receive Food Stamps or Cash Assistance or Reduced Lunch at school?
*
Food Stamp
Reduced lunch at school
Cash Assistance
None of the above
Other:
Have you ever been involved with the justice system?
*
Yes
No
Have you ever been diagnosed with a disability?
*
Yes
No
Are you a High School or GED graduate?
*
Yes
No
If you are not a high school or GED graduate, what was the
highest grade
you completed?
*
Your answer
What was the name of the last school you attended? Provide the full name.
*
Your answer
If you dropped out of school, how many months have you been out of school?
*
Your answer
Are you currently enrolled or attending any school or college?
*
Yes
No
If yes,
what is the name of the school or college
and
what are you studying
? Provide details.
Your answer
What are your educational and career goals
?
What is the one goal
CPLC's WIOA Youth Program can help you with?
*
Your answer
Are you currently working?
*
Yes
No
If yes, Part Time or Full Time?
Part time
Full time
Clear selection
If unemployed, for how many weeks have you been unemployed?
Your answer
Do you have reliable transportation?
*
Yes
No
Do you have internet service at home?
*
Yes
No
Do you have access to a computer at home?
*
Yes
No
Please list one reliable person who would know how to get in contact with you if we are unable to reach you.
List Person's
Name
,
Relationship
,
Address
, City, State, Zip, Home Phone, Work Phone,
Cell Phone and email address.
*
Your answer
Please list 2 people, who can be contacted in the event of an emergency.
Emergency Contact #1
- Name, Relationship, Address, City, State, Zip, Home Phone, Work Phone, Cell Phone
*
Your answer
Emergency Contact #2
- Name, Relationship, Address, City, State, Zip, Home Phone, Work Phone, Cell Phone
*
Your answer
For CPLC Internal Use Only (applicant, please do not select anything for this area)
T2
T3
Clear selection
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