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Chicanos Por La Causa YouthBuild Las Vegas Application*
Please fill out the application to its entirety do not leave any sections blank.
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Name
First and last name
Your answer
Date of Birth
Your answer
Age
Your answer
Gender
Male
Female
Clear selection
Race/Ethnicity
Your answer
Mailing Address: street #, street name, city, state, zip
Your answer
Cell Phone
Your answer
Alternative Phone number
Your answer
Email Address
Your answer
Are you a United States resident?
Yes
No
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Name, Address and phone number of someone who can always reach you
Your answer
I am currently living with (check all that apply)
Parent/guardian
Spouse and/or children
Alone
With a friend
Homeless Shelter
Other:
Are you registered for the selective services?
Yes
No
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Have you ever been in foster care?
Yes
No
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Do you have a drivers license?
Yes
No
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Have you ever been convicted of a crime? (Please answer honestly, answering "yes" will NOT hurt your chances of being selected for CPLC YouthBuild Las Vegas)
Yes
No
Clear selection
If you answered "yes" to the previous question, please describe the charges, date and status of the case
Your answer
Do you have any active court cases?
Yes
No
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If you answered "yes" please list the charges
Your answer
Are you on probation or parole?
Yes
No
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If you answered "yes" to the previous question please list the name and number of your probation/parole officer
Your answer
How did you hear about CPLC YouthBuild Las Vegas?
Your answer
Name, city and state of the last school you attended
Your answer
Dates you attended
Your answer
Last grade you completed
Your answer
Have you taken any vocational or construction education classes?
Yes
No
Clear selection
Are you Currently in a GED/HiSET program?
Yes
No
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If you answered "yes" to the previous question which Program/School are you attending?
Your answer
If you have not obtained a High school diploma or high school equivalency, please explain why?
Your answer
Which would you like to attend following completion of you Diploma or Equivalency?
Apprenticeship program
2 year college
Certification program
Military Service
Other:
Have you ever participated in another job-skilled training program?
Yes
No
Clear selection
If "yes" to the previous question which program and when? Are you still enrolled in the program?
Your answer
Do you have any construction or construction rehab experience?
Yes
No
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Have you ever had a job?
Yes
No
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If you answered "yes" to the previous question Please list your most recent Jobs, Dates you worked, company, job title, hourly wage, reason for leaving?
Your answer
If you are currently employed, how many hours do you work each week?
Your answer
Have you ever been involved or enrolled in another YouthBuild program?
Yes
No
Clear selection
CPLC YouthBuild Las Vegas will meet Monday-Friday from morning to afternoon (8am-3:30pm) Will your work schedule at your job conflict with this?
Yes
No
Clear selection
How comfortable are you using computers?
Very- I can run programs, surf the web, etc.
A little- I can type papers and send emails
I don't really use computers
Clear selection
Are you required to wear eye glasses or contacts?
Yes
No
Clear selection
Do you understand that CPLC YouthBuild will involve several months of hands-on construction training and that you will be expected to fully participate in indoor and outdoor construction?
Yes
No
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If so to the previous question do you agree to participate in all activities inside and outside of the classroom?
*
Yes
No
Please list two individuals we can reach in case of an emergency and let them know you have listed them. Include cell and home phone number.
*
Your answer
Are you receiving any assistance such as TANF/Food Stamps, subsidized housing, Medicaid or others?
Yes
No
Clear selection
If you answered "yes" to the previous question please list all benefits you are receiving.
Your answer
YouthBuild is a program that will support and challenge you to transform your life and your future. Please answer the following question in paragraph form, to the best of your ability
Your answer
What makes you want to participate in YBLV?
Your answer
What goals (for your life, your future your family, etc) will you use to stay motivated and give your best effort through 36 weeks (9 months) of hard work
Your answer
I certify that the information in this application is true and correct to the best of my knowledge. I also authorize YouthBuild Las Vegas to verify this information when reviewing my eligibility for the program. I understand that I may be asked to provide documentation and agree to sign, if asked, one or more release forms to allow YouthBuild Las Vegas to verify the information provided in this application. PLEASE SIGN YOUR FULL NAME BELOW IN COMPLETION OF THIS APPLICATION.
*
Your answer
Please be aware that YouthBuild Las Vegas is funded through the Department of Labor and required to obtain the following documentation upon interview. Please check all documentation required that you currently have in your possession.
Nevada state ID or Nevada State Drivers License
Social Security Card
Birth Certificate
Registration for Selective Services (Male Only)
Copies of your TANF Card, Medicaid Card including paper documentation (if applicable)
“This organization Chicanos Por La Causa/YouthBuild Las Vegas received a $1.4 million grant at 75 percent of funding from the U.S. Department of Labor – Employment and Training Administration to administer a YouthBuild program. Our organization will be providing a 25 percent match contribution toward the YouthBuild grant. An equal opportunity employer/program Auxiliary aids and services are available upon request for Individuals with disabilities Relay 711 or (800) 326-6868.” CPLC YouthBuild Las Vegas is a proud YouthBuild AmeriCorps program offering 20 service member slots to participants to complete 450 service hours in the Las Vegas valley by building affordable homes and other community service projects. After completion of the service term requirements, YouthBuild AmeriCorps members earn a Segal Education Award that can be used to pay for education expenses at post-secondary institutions and technical schools or re-pay qualified school loans.
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