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YOUTH WORKS! Pre-Application
Are you a United States citizen or legal alien? Yes No *IF NONE OF THE BELOW APPLY PUT N/A ON THE SPACE AVAILABLE*
Do you have a disability? Yes No If yes, please list
Do you have a high school diploma? Yes No If yes, school & graduation date
Are you currently attending high school? Yes No If yes, school & current grade
*If no, most recent school & grade completed______
Do you attend an alternative school? Yes No School/Current Grade
Have you participated in a Tech-Ed Program? Yes No Program:
Do you have a GED certificate? Yes No Date received
If you are a male and are over 18, are you registered with the Selective Service? Yes No N/A
Primary Language: English Spanish Other:
PLEASE CHECK ALL THAT APPLY:
Foster child/Ward of court Emancipated Youth Drop-Out Pregnant or Parenting Teen Homeless
Incarcerated Youth Runaway IEP Date of last IEP: ______
Failure of one or more years of school Offender (misdemeanor or felony)
Do you or any of your family members (living with you) receive any of the following? IF NO, please mark the box labeled “No”
FIP (cash assistance) Yes No Medicaid Yes No Food Stamps/Bridge Card Yes No
Refugee Assistance Yes No Social Security Income Yes No
If yes, please circle type Retirement Disability Survivor
Name of Member (Include yourself) Relationship Age Type of Income (if any) Approx. Income in last 6 mos.
1.Youth Name: / SELF / $2. / $
3. / $
4. / $
5. / $
6. / $
7. / $
What type of training assistance are you requesting?
GED How many of the five required tests do you need? ______What program do you plan to attend? ______
HS Credit Recovery How many total credits do you need assistance with? ______Program?______
Post-Secondary Training School? ______Program? ______
Youth Work Experience Job Search & Career Exploration Workshops Other-______
Support Services or Referrals needed for any of the following:
Transportation Housing Clothing for work Chemical dependency Child care
Legal Assistance Medical/Health issues Counseling Other
Work History: Yes No If yes, please complete all information below.
Employer Address
Start Date (Month/Year) End Date (Month/Year) Hourly wage Job title
Employer Address
Start Date (Month/Year) End Date (Month/Year) Hourly wage Job title
1. Future plans (circle all that apply): College Military Employment Trade/Vocational School Uncertain
What are your long-range educational or training interests?
If you see obstacles in obtaining these goals, please indicate what these may be: ______
2. Please list all/any certifications you have earned (Example: CPR/First Aid)
Skill Date Acquired Certified: Yes No
Skill Date Acquired Certified: Yes No
3. Job Interests: Clerical (office) Work indoors Work with the elderly Work outdoors
Work with animals Grounds / landscaping Work with a team Like to clean Work by yourself
Are you related to anyone involved in the Administration of the WIA program, including at the AAESA, ACSET, Michigan Works or State of Michigan? Yes No If yes, please give the persons name and location of Michigan Works Agency
I certify that I have reviewed this application and that the information given is true to the best of my knowledge. I also understand that the information I have provided is subject to review, and verification. I understand that I must provide documents to support this information, and the refusal to provide such documents will cause me to be ineligible. I am also aware that I am subject to immediate termination if found ineligible after enrollment, and may be prosecuted if I have falsified or fraudulently provided information. The following agencies are hereby authorized to give and receive information for determining eligibility, delivering employment:
*Michigan Rehabilitation Services *Community Mental Health *Probation Department
*Financial Aid for Higher Education *Family Independence Agency *Michigan Unemployment Agency *Friend of the Court *Employers *Area Community Services Employment &Training
*Others: Schools to verify: address, residence, grades, attendance report free or reduced lunch programs, age, birth date, disabilities.
I understand I may be required to complete the Work Keys Assessment in Math, Reading and Locating Information at enrollment into the WIA Youth Program and possibly a post-test prior to exit.
______
Signature of Applicant Date Signature of Parent / Guardian (If applicant is not 18)
The Boards of Education of Allegan Area Educational Service Agency, Allegan, Fennville, Glenn, Hopkins, Martin, Otsego, Plainwell and Wayland comply with all federal laws and regulations prohibiting discrimination on the basis of race, color, religion, national origin or ancestry, age, sex, marital status or handicap.
G:\Case Management\WIA enrollment info - forms\Youth Enrollment Forms\Enrollment Forms\1 Pre-Application - YOUTH.doc