Section I
    A. Identification

    Your Name (required)

    Your Telephone Number (required)

    Your Message Number (required)

    Your Address (required)

    Your Date of Birth

    Your Age

    Gender
    MaleFemale

    Race

    Marital Status
    SingleMarriedOther


    B. Characteristics

    Are you an individual with Disability/Health Limitations?
    YesNo
    If yes,

    Does your family receive food stamps?
    YesNo

    Are you pregnant or a parent?
    YesNo

    Are you an offender or have an arrest record?
    YesNo
    If yes,

    Is English your natural or your most comfortable language?
    YesNo

    Have you received treatment for substance abuse?
    YesNo

    Are you homeless?
    YesNo

    Are you a foster child?
    YesNo

    Are you a child of an incarcerated parent?
    YesNo

    Do you receive cash or medical assistance?
    YesNo


    C. Educational Information

    Are you a high school dropout?
    YesNo
    Highest Grade Completed
    Year withdrew

    Did you obtain a GED?
    YesNo
    Month/Day/Year

    Are you currently in a GED Program?
    YesNo

    What is the last school you attended?


    D. Veteran Status

    If you are 18 or older, have you registered with Selective Service?
    YesNo

    If Yes, please list your Selective Service Number


    E. Work History

    Have you ever been employed in the last six months?
    YesNo
    If yes,please list the employer

    Period of Employment (From-To)

    Hours Per Week

    Hourly Wage


    Please answer the following questions:
    1. What interests you about the Uniontown YouthBuild program?

    2. Are there any issues that you think may interfere with your ability to fully participate in the program?

    3. What are your greatest strengths?

    4. What are your hobbies?

    5. What do you hope to get out of this program?