YouthBuild Application Contact Form First Name * Middle Name Last Name * Date of Birth * Email Address * Street Address * City * State * Please select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin IslandNorthern Mariana IslandsGuamAmerican SamoaPalau Zip Code * County * Please select...AustinBrazoriaChambersFort BendGalvestonHarrisLibertyMatagordaMontgomeryWallerWalkerWhartonOther Other County * Preferred Phone * Please select...HomeWorkMobile Mobile Phone * Home Phone Work Phone How did you hear about YouthBuild? * Please select...Agency Partner Referral (HCC, United Way, Workforce Solutions, etc.)EmailInternet SearchJob Fair / Community EventJob Website (Craigslist, Indeed, Linkedin, etc.)OtherSign / BillboardSocial MediaWord of Mouth (Friends, Family, SERJobs Staff / Client) If not listed, please indicate below: Demographic Information Gender * Please select...FemaleMaleTransgender MaleTransgender Female Are you Head of Household? * Please select...YesNo Female Head of Household? * Please select...YesNo Do you consider yourself Hispanic or Latino? * Please select...YesNo Race * Please select...American Indian/Alaskan Native & Black/African AmericanAmerican Indian/Alaskan Native & WhiteAmerican Indian or Alaskan NativeAsian (not Pacific Islander)Asian & WhiteBlack/African American & WhiteBlack or African AmericanHawaiian Native or Pacific IslanderOtherWhite or CaucasianMulti-Racial Do you need any special accommodations in order to participate in this program? * VisualHearingSpeechLimited MobilityNot Applicable Check all that apply. Please check the "Not Applicable" box if you do not need any special accommodations. Are you authorized to work in the United States? * Please select...YesNo Do you have a valid form of identification? * Please select...YesNo Social Security # * What type of identification do you have? * Please select...Texas Issued Driver's LicenseOther State Issued Driver's LicenseTexas Issued Identification CardOther State Issued Identification CardPassport What type of Driver's License do you have? * Please select...CLASS ACLASS BCLASS CCLASS M ID Number * What is your primary method of transportation? * Please select...Own/lease vehicleCan borrow vehiclePublic transitOwn/lease vehicle but it's inoperable/not reliable What is your housing status? * Please select...HomeownerRenter-Unsubsidized (not receiving public assistance)Renter-Subsidized (receiving public assistance to cover your rent)Living with a friend/ familyStaying in a shelterHomeless [conditional conditional-housing-status] Are you at risk of becoming homeless? * Please select...YesNo [/conditional] Are you registered with a selective service? * Please select...YesNoNot SureNot Applicable Are you over 24? * Please select...YesNo Household and Family Info Marital Status * Please select...SingleMarriedDivorcedSeparatedWidow/Widower What is your household's annual income? * Please enter your annual household income. Your best estimate will suffice. How many children 17 years old and under live in your household? * You should include/count yourself in only one of these categories in addition to other household members. How many young adults 18–24 years old live in your household? * You should include/count yourself in only one of these categories in addition to other household members. How many adults over the age of 24 years old live in your household? * You should include/count yourself in only one of these categories in addition to other household members. If interested: We offer financial coaching & help individuals open a checking and/or savings account, who don't currently have a checking / savings account. Do you have a checking account? * Please select...YesNo Do you have a savings account? * Please select...YesNo Emergency Contact Information Emergency Contact Name * Emergency Contact Relationship to You * Emergency Contact Phone * Alternate Contact Name * Alternate Contact Phone * Next Public Assistance Benefits Are you currently receiving any of the following forms of public assistance? Breakfast & Lunch ProgramCHIP (Children's Medicaid)HeadstartMedicaidSNAP (Supplemental Nutrition Asst Program)TANF (Texas Temp. Asst for Needy Families)WIC (Women, Infants, and Children) Employment History What is your current employment situation?* Employed (including self-employed)Recently received notice of terminationUnemployed (receiving unemployment benefits)Unemployed (NOT receiving unemployment benefits)FurloughedLaid Off In the next section, please fill in information about your most recent job or current job, if applicable. Job Title Employer Name Job Type Full Time (30+ hours)Part Time (less than 30 hours) Job Commitment PermanentInternshipTemporary/Seasonal Job Start Date Job End Date Hourly Wage Average Hours per Week Name of Supervisor Supervisor's Job Title Reason for Leaving Education History What is the highest level of education that you have reached? * Please select...Some High SchoolHigh School DiplomaGEDSome CollegeAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate Are you currently attending school? * Please select...YesNo Are you interested in pursuing post secondary education after earning your GED? * What is your English Literacy level (ability to read/comprehend)? * Please select...BeginnerIntermediateAdvancedFluent How would you rate your computer skills? * Please select...BeginnerIntermediateAdvancedExpert Please list any certificates you have earned or relevant training experience here: Military Status Are you a veteran? * Please select...YesNo Military Status * Please select...Honorable DischargeGeneral DischargeOther Than HonorableDishonorableStill Serving Date of Discharge * Which branch did you serve in? * Please select...ArmyArmy National GuardAir ForceAir National GuardNavyMarine CorpsCoast Guard Justice Involvement Have you ever been convicted of a crime(s)? * Please select...YesNo Crime Details What is the highest conviction that you have received? * Please select...MisdemeanorFelonyOther Charge(s) * Aggravated assaultAssaultCareless/Reckless DrivingDisorderly ConductDrug PossessionDWIFraudRobberyShopliftingTheftTrespassingVandalismOther Please provide a brief explanation of your conviction: * Are you currently on: * Please select...ProbationParoleNone What date does probation/parole end? Have you ever been incarcerated? * Please select...YesNo Date of release: Total time incarcerated: #of Years #of Months Are you currently residing in a halfway house? Please select...YesNo Are you currently wearing a Super Intensive Parole Monitor (ankle monitor)? Please select...YesNo BackNext Training Do you have a smartphone? * Please select...YesNo Do you have internet access at home? * Please select...YesNo Do you have access to a computer at home? * Please select...Yes, I have a personal computerYes, I have a computer that I share with others at homeNo, I do not have a computer Are you interested in training? * Please select...Yes, I am interested in trainingUnsure at the moment, need to learn more about available optionsNo, I am not interested in training The training opportunity I am seeking is? * Please select...NCCER CORE & OSHA 10CUSTOMER SERVICEPHLEBOTOMY Essay Question In your own words please state why you are interested in being selected for the YouthBuild Houston Program. * Services you are seeking Highest Priority * Please select...Job PlacementTrainingGEDSupport Services Medium Priority * Please select...Job PlacementTrainingGEDSupport Services Lowest Priority * Please select...Job PlacementTrainingGEDSupport Services What is your availability for these activities? * Full time (30+ hours per week)Part time (20 hours or less per week)Days (8am to 5pm)Evenings (6pm to 10pm)Weekdays (Monday–Friday)Weekends (Saturday & Sunday) How much time are you able or willing to invest in a program? * Please select...Less than 5 hours per week5–10 hours per week10–20 hours per week20+ hours per week What do you believe has kept you from getting a job? * BackgroundHomelessnessLack of SupportLearning DisabilityPhysical DisabilitySubstance AbuseNeed of TrainingMeans of TransportationNeed of Child CareOtherLack of Education Are you able to take and pass a drug screening within 24 hours? * Please select...YesNo What is your wage expectation? Minimum hourly rate Are you interested in sharing your SER story after receiving SER services? * Please select...YesNo Is there anything else you think we should know? One of our YouthBuild Staff members will contact you during our scheduled hours of operation (Monday – Friday, 8AM – 4PM), to discuss next steps towards enrolling in YouthBuild Houston. Our office number is 713-773-6000. When’s the best day to be contacted? * Any day Mon - FriMondayTuesdayWednesdayThursdayFriday When’s the best time to be contacted? * Anytime 8AM-5PMMorning 8:00-11:30AMMidday 11:30-2:00PMAfternoon 2:00-5:00PM Back
