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The following information is used to determine eligibility and will be kept confidential.

Date:
Name:
Address:
City:
State:
Zip:
Phone:
Cell Phone:
Social Security #:
U.S. Citizen:	Yes No
Ethnic Background:	African American Asian Hispanic Native American Vietnamese White Multi-Culture
Emergency Contact 1:
Emergency Contact 2:
Where did you hear about YouthBuild:	NewsPaper Radio TV Flyer School Friend Other
If other explain:
Do you have a High School diploma:	Yes No
Do you have a GED:	Yes No
Last school attended:
Last grade completed:
If you dropped out, how credits did you have:
If you dropped out, why:
Did you take any Vocational or Tech courses:	Yes No
If so which ones:
Did you receive Special Education services:	Yes No
Do you have any documented disabilities:	Yes No
Do you know how to drive:	Yes No
Do you have a permit or driver's liscense:	Yes No
Do you own a car:	Yes No
Have you ever been in another training program:	Yes No
If yes give location and program:
Date you attended program:
Did you complete program:	Yes No
What are you interested in doing for a career:
Have you ever held a job:	Yes No
Name of business:
Address of business:
Business city:
Business State:
Business Zip:
Employment start date:
Employment end date:
What kind of work you do:
Supervisor's name and title:
Why did you leave:
Are you currently working:	Yes No
What is your job:	Full-Time Part-Time
Currently hourly wage:
Hours worked per week:
Name of business:
Address of business:
Business city:
Business State:
Business Zip:
What kind of work do you do:
Supervisor's name and title:
Have you had previous contruction or building experience:	Yes No
If yes, please describe:
Do you have any mental and emotional health problems:	Yes No
If yes, please describe:
Are you supposed to contacts or glasses:	Yes No
Do you have asthma:	Yes No
Do you have diabetes:	Yes No
Do you have any known allergies:	Yes No
If yes, please describe:
Do you smoke:	Yes No
When was the last date of physical examination:
Have you ever been convicted of a crime:	Yes No
If yes, please describe:
Are you on prohibation, parole or involved with corrections:	Yes No
Probation/Parole officer:
Probation/Parole officer number:
Do you or any of your family receive the following:	Social Security FIP Food Stamps Title XIX Unemployment
Are you a parent:	Yes No
Do you live with your parents:	Yes No
If not, with whom do you live with:
Number of people in household including you:
Approximate income of household in the last 12 months:
Why are you interested in this program:
What do you hope to gain from this program:
Date of Birth:

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