YBL Student Application Form

YouthBuild Louisville: Student Application

YouthBuild Louisville is dedicated to providing the most comprehensive service for each participant, and in order to ensure YouthBuild’s ability to best serve you, the following form must be completed thoroughly. Please fill out each item as directed.
Name:*

First NameMiddle NameLast Name
Nickname
Age*
Birth Date*

MonthDayYear
Phone Number:*

Area CodePhone Number
Other Number:

Area CodePhone Number
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Education:
Last School Attended:*
Do you have your High School Diploma? (HSD)*

YesNo
If not, what was the highest grade you completed?*
Number of years out of school?*
Do you have your GED?*

YesNo
Eligibility
Gender*

MaleFemale
US Citizen Status*

YesNo
Authorized to work in the US?*

YesNo
Registered to Vote?*

YesNo
Do you have your Driver's License?*

YesNo
Registered for Selective Service? (NOTE: If you are Male and 18 years old, you MUST be registered. We will help you complete this process.)*

YesNoNot Applicable (Female or under 18)
Employment Status as of today:*

Employed Full TimeEmployed Part TimeUnemployed (Actively Looking)Unemployed (Not Looking)
Race*

AsianWhiteNative or other Pacific IslanderBlack or African AmericanAmerican Indian or Alaskan HawaiianOther
Marital Status:*

SingleMarriedDomestic PartnerDivorced
Household Income:*

None$1 - $10,000$10,001 - $20,000$20,001 - $30,000$30,001 - and aboveOther
Public Assistance (Indicate ALL that apply as of today)*

No BenefitsSSITANF/K-TAPPublic Assistance/ Non-TANFUnemployment InsuranceFood Stamps (SNAP)Public Housing
Check all that apply to you:*

Low-income familyMigrant YouthYouth in Foster CareAged out of Foster CareYouth OffenderChild of Incarcerated ParentImmigrantHomelessVeteranHave Documented Disability
How did you hear about YouthBuild Louisville?*

Referred by Guidance CounselorReferred by Case ManagerReferred by Probation/ Parole OfficerReferred by Friend/ Colleague/ RelativeAdvertisement/ Flyer
Name of referring person:
Fields of Interest:*

Construction TradeNursing AssistantUrban ConservationCulinaryNone of the above
Job Skills & Training
Do you have a resume? If so, upload it below. Do you have other skills you would like to tell us about? Have you attended any trainings or have any certifications you would like us to know about? If so, list those in the appropriate areas below.
Describe your skills:
Training or Certifications:
YouthBuild Louisville is an equal opportunity organization and will not allow discrimination based upon age, ethnicity, ancestry, gender, national origin, disability, race, size, religion, sexual orientation, socioeconomic background, or any other status prohibited by applicable law.

If reasonable accommodation is needed, please contact us at 502-290-6121. YouthBuild Louisville is committed to the full inclusion of all qualified individuals. As part of this commitment, YouthBuild Louisville will ensure that persons with disabilities are provided reasonable accommodations.
Signature

I HEREBY CERTIFY THAT THE ANSWERS GIVEN BY ME ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER CERTIFY THAT I, THE UNDERSIGNED APPLICANT, HAVE PERSONALLY COMPLETED THIS APPLICATION. I VERIFY BY MY SIGNATURE THAT THE ABOVE ADDRESS IS MY CORRECT LIVING ADDRESS. I HEREBY AUTHORIZE YOUTHBUILD LOUISVILLE TO THOROUGHLY INVESTIGATE MY WORK RECORD, EDUCATION AND OTHER MATTERS RELATED TO MY SUITABILITY FOR ACCEPTANCE INTO THE PROGRAM. PLEASE ENTER YOUR INITIALS IN THE SPACE BELOW, INDICATING YOUR AGREEMENT TO THE TERMS LISTED ABOVE. YOUR INITIALS IN THE SPACE BELOW ACT AS YOUR SIGNATURE TO THIS DOCUMENT.
INITIALS*
Should be Empty:

YouthBuild Louisville: Student Application

Education:

Eligibility

Job Skills & Training

Signature