First Name:
Middle Name:
Last Name:
Street Address:
City:
State:
Zip Code:
Home Phone Number:
Cell Phone Number:
Email Address:
How Did You hear about HOY:
Demographic Information
Date Of Birth:
Gender:
Male
Female
Hispanic/Latino?
Yes
No
Number Of People In Household:
Estimated Total Household Income:
$0-$5,000
$5,001-$9,999
$10,000-$14,999
$15,000-$24,999
$25,000-$34,999
$35,000-$49,999
$50,000 or more
Work Authorization Status:
US Citizen
Eligible Non-Citizen
No Response
Current Employment Status:
Employed Full-Time
Employed Part-Time
Not Employed
Employed - Received Termination Notice
Last Education Level Completed:
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
H.S. Diploma
Earned GED
1 year post H.S.
2 years post H.S.
Earned 2 year degree/diploma
Other
Current Education Status:
Student, Middle School
Student, High School
Student, Alternative High School
Student, Post H.S. Education
Not a Student, H.S. graduate/GED
Not a Student, No H.S. diploma/GED
Assesment Of Challenges To Employment/Education
The youth programs assist youth in overcoming any barrier to employment or education. These questions are to assess need only. Please answer the following questions to the best of your ability.
Is English Your second language?
Yes
No
Are you from a single parent home?
Yes
No
Are you a single parent with primary responsibility for your child(ren)?
Yes
No
Are you in foster care?
Yes
No
Are you adopted?
Yes
No
Are you currently homeless?
Yes
No
Are you a runaway youth?
Yes
No
Are you on probation?
Yes
No
Do you need assistantance cleaning up a criminal record?
Yes
No
Are you pregnant or a parent?
Yes
No
Do you have a drivers license?
Yes
No
Do you have your own reliable transportation?
Yes
No
Are you behind a grade level in school?
Yes
No
Please list any additional barrier(s) you may have:
Submit
Should be Empty: