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YouthBuild Application and Information form

The Department of Labor recently announced SMRCDC as its 2019-2022 the YouthBuild program in Memphis. The YouthBuild program is administered by the Employment and Training Administration’s Office of Workforce Investment, Division of Youth Services.

Participants Information

First Name *

Middle Initial *

Last Name *

Date

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date of Birth

Place of Birth: City, County, State

Phone

Email Address

YBM Training Modularity Interested In:Construction TrainingCertified Nursing AssistantManufacturing TechnologyComputer Technology Certifications

How did you hear about the Programs?RadioSocial MediaFriendAnother Program

Date Available

Month

Day

Year

Social Security Number

Selective Service

Status

RaceEthnicity:

Are you a US Citizen

If No; INS Alien Document Number:

Expiration Date:

Is English the Applicant’s First Language:

If No, Please specify

Native American

Tribe

Does Applicant have a CDIB Card?

Individual with a Disability

Information regarding Disability:

Are you an ex-offender (This does not disqualify you.)

Does the Applicant have a current Department of Rehabilitation Service Case?

Emergency Contact:

First Name

Last Name

Relationship:

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Education Information

High School Name

Street Address

City

State/Province

ZIP / Postal Code

From:

Did you graduate?

Diploma

ADDITIONAL STUDENT INFORMATION

Participants Youth Build Goals

GOALSObtain a JobImprove Current Job PayResponsibilitiesImprove Reading SkillImprove Math SkillsImprove Speaking SkillsObtain Citizenship

REFERSouthwest CCEmployerFriends/FamilyLibraryFacebookSocial MediaYouthbuild Alumni

I authorized the release of my photograph for CLC use

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

DATA

Household Income (approximate)

Number of People in Household:

Children (under 18)

Adults

Upload Birth Certificate

No file chosen

Upload Copy of Drivers License

No file chosen

Social links

Test scores cannot be made available to third parties without the signed consent of the test take. We will not disclose any personal data regarding any participant. If information is to be release, the written consent of each participant will be requested prior to release. Participant will be asked to sign a photography release form for authorization of release of photos to be use in marketing materials.

Disclaimer and Signature *

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to acceptance in YouthBuild Memphis, I understand that false or misleading information in my application or interview may result in my release.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Date

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