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 WhiteAfrican-AmericanOther 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?
