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Student Application
Name
*
First
Last
Where did you hear about the LearningWorks YouthBuild program?
Background Information
Mailing Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
*
Additional Phone Number
Email Address
How may we best contact you (check all that apply)
Select All
Text Message
Phone
Email
Regular Mail
Date of Birth
*
MM
DD
YYYY
Age
*
Sex
*
Female
Male
What pronouns should we use when referring to you?
She/Her/Hers
He/Him/His
They/Them/Theirs
I use multiple pronouns.
If you use multiple pronouns, you may list them here.
Social Security Number
Are you MaineCare eligible?
Yes
No
Not sure
MaineCare ID#
Emergency Contact / Legal Guardian
Name
First
Last
Relationship to you
Mailing Address
Street Address
Address Line 2
City
state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Other
Names and Numbers of two close friends or relatives:
Name
First
Last
Phone
Relationship
Name
First
Last
Phone
Relationship
Racial or Ethnic Origin (Mark all that apply)
African American/Black
American Indian/Alaskan Native
Hawaiian/Pacific Islander
Asian
Latina/Latino/Latinx
White
Other (Specify)
Other (Specify)
Primary Language
Are you a U.S. Citizen?
*
Yes
No
Do you have a valid work permit?
Yes
No
Not Sure
Marital Status?
Single
Married
Separated
Divorced
Widowed
Please estimate the gross income in the household where you live during the last 12 months. Include job wages, pension, social security, retirement income, alimony, unemployment compensation, child support, AFDC, general assistance, other welfare, SSI, and SSDI payments. Include earning for all family members, not roommates.
$0 - $5,000
$5,001 - $10,000
$10,001 - $15,000
$15,001 - $20,000
$20,001 - $25,000
$25,001 - $30,000
$30,001 - $35,000
$35,001 - $40,000
$40,001 - $45,000
$45,001 - $50,000
Over $50,000
Number of people living in your household including you
Do you live in Public Housing?
Yes
No
Do you have a Section 8 Housing Certificate?
Yes
No
Do you live in a halfway house or group home?
Yes
No
Do you live in a shelter?
Yes
No
Are you homeless?
Yes
No
Have you ever been homeless?
Yes
No
Education
Please provide a copy of GED/HiSET, Diploma and/or high school transcript.
Do you have a...
*
GED/HiSET
High School Diploma
Neither
What is the highest grade level you have completed?
Why are you not in the public school system?
Did you drop out of school and plan not to return?
Yes
No
If yes, when did you last attend?
Month
1
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11
12
Day
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1933
1932
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1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
How many credits have you earned at your high school?
What school did you last attend?
*
Work Experience
Are you currently employed?
Yes
No
Name of company where employed
Number of hours worked per week
Pay rate per hour
Do you earn employer benefits?
Yes
No
In the last 12 months, have you been employed?
Yes
No
Name of company where employed
Date last job ended
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Number of hours worked per week
Pay rate per hour
If unemployed, are you currently looking for a job?
Yes
No
Dependents and Public Assistance
Who do you live with? (Parents, Grandparents, your child(ren), friends, etc)
How long have you lived at your current address?
Less than 6 months
6 to 12 months
Over 12 months
Are you a parent?
Yes
No
If yes, how many children do you have?
What are their birth dates?
Do you live with your children?
Yes
No
If no, does your child(ren) receive TANF?
Yes
No
Are you currently in foster care?
Yes
No
Are you in DHHS custody?
Yes
No
If yes, how long have you been in DHHS care?
Name of DHHS caseworker
Telephone
Do you or does someone else in your household receive:
TANF
Food Stamps/SNAP
General Assistance
SSI or SSDI
None of the above
Don’t know
Corrections System Experience
Have you ever been arrested?
Yes
No
If yes, how many times?
Did you participate in an Intensive Aftercare program?
Yes
No
Juvenile Detention?
Yes
No
Facility
Detention dates, offenses
Committed?
Yes
No
Facility
Commitment dates, offenses
Adult Detention?
Yes
No
Facility
Detention dates, offenses
Adult Incarceration?
Yes
No
Facility
Incarceration dates, offenses
Are you currently detained?
Yes
No
Committed or Incarcerated?
Yes
No
Facility
List offenses that resulted in your detention, commitment or incarceration
Have you ever been on Supervised Conditions of Release?
Yes
No
SCR started
Month
1
2
3
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5
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12
Day
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2011
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2002
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1991
1990
1989
1988
1987
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1984
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1982
1981
1980
1979
1978
1977
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1975
1974
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1969
1968
1967
1966
1965
1964
1963
1962
1961
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1958
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1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
SCR ended
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
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2020
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2011
2010
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2002
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1991
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1989
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1987
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1981
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1962
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1955
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1953
1952
1951
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1949
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1947
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1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Have you ever been on probation?
Yes
No
Probation started
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
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2020
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2011
2010
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2008
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2002
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2000
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1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Probation ended
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
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2020
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2018
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2010
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2002
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1941
1940
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Are you currently on probation?
Yes
No
Supervised Conditional Release?
Yes
No
Started
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
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2019
2018
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2011
2010
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2002
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Expected end date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
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1935
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Explain Reasons for probation/SCR
Do you have any court dates coming up?
Yes
No
Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
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5
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2020
2019
2018
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2015
2014
2013
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2011
2010
2009
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2006
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2002
2001
2000
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Have you ever been convicted of a misdemeanor?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Name of Probation Officer
Phone
Name of Lawyer
Phone
Other Background Information
The following questions are for our records only. Please note that your past history will not prevent you from being accepted into our program.
Do you have a history of alcohol or drug misuse or abuse?
Yes
No
Have you ever received treatment for alcohol or drug related problems?
Yes
No
Specify
Do you have a substance abuse counselor?
Yes
No
Specify
Is there a history of alcohol or drug abuse in your family?
Yes
No
Specify
Do you have any type of disability besides substance abuse? (This question is optional)
Yes
No
Specify
Do you see a counselor?
Yes
No
Name of counselor
Phone
What day and time do you go to the counselor?
Are you connected with any other services?
Yes
No
If yes, please list the name(s), reason(s), and phone number(s) of all services.
If you were enrolled in any other programs before LearningWorks YouthBuild, please specify
Do you have an active driver’s license?
Yes
No
Do you have a valid driver’s permit?
Yes
No
Are you registered to vote?
Yes
No
Are you registered for selective service?
Yes
No
Are you an emancipated minor?
Yes
No
Application Essay
Please write a brief essay explaining the following (Format is not important): a. Why do you want to be in the program? b. How will your involvement in LearningWorks YouthBuild assist you in pursuing future goals? c. List 3 goals that you want to work toward if you are accepted into the program.
Phone
This field is for validation purposes and should be left unchanged.
