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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
*
Month
Day
Year
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
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
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
Education
What school did you last attend? (please include name and address)
*
In school, did you have:
IEP
504
Not sure
Work Experience
Are you currently employed?
Yes
No
Name of company where employed
Number of hours worked per week
Pay rate per hour
If unemployed, are you currently looking for a job?
Yes
No
Public Assistance
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
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 any type of disability? (learning disabilities, ADHD, autism spectrum, anxiety/depression)
*
Yes
No
Specify- disability and when diagnosed
Are you connected with any other services? (case management services, housing assistance, substance abuse etc)
*
Yes
No
If yes, please list agency name(s), reason(s), and phone number(s) of all services.
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.
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