Out of School Youth Program Application

Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone *

(###)

###

####

Cell Phone *

(###)

###

####

Checkbox *

Do you accept text messages?

Yes

No

Message Phone *

(###)

###

####

Relative's Name *

First Name

Last Name

Relative's Phone *

(###)

###

####

Birthdate *

MM

DD

YYYY

Sex (at birth) *

Male

Female

Are you Hispanic or Latino? *

Yes

No

Prefer not to answer

What is your Race? *

Select one or more:

White or Caucasian

Asian or Asian American

Black or African American

Hawaiian or Other Pacific Islander

American Indian or Alaska Native

More than one race

Prefer not to answer

Do you acknowledge a disability that substantially limits one or more major life activity? *

Yes

No

If yes, do you need special accommodations for the disability?

Yes

No

Do you receive Social Security Disability Insurance? *

Yes

No

Do you have trouble solving problems OR reading, writing, and speaking English at a level necessary to function on the job? *

Yes

No

Is English your primary language? *

Yes

No

Do you live in a family or community where English is not the primary language spoken? *

Yes

No

Are you registered with Selective Service? *

Yes

No

Are you a U.S. Citizen? *

Yes

No

If no, are you a permanent resident alien?

Yes

No

If no for both above, are you a lawfully admitted refugee, asylee, parolee, or other immigrant authorized to work in the United States?

Yes

No

N/A

Are you a veteran? *

Yes

No

Are you the spouse of a veteran? *

Yes

No

Are you a widow or widower of a veteran? *

Yes

No

Have you registered with Arkansas Job Link? *

Yes

No

Are you an Arkansas Works referral from the state Medicaid expansion program? *

(Arkansas Works is a Governor's initiative DHS program that refers DHS clients to DWS job service staff for employment assistance)

Yes

No

Have you been subject to any stage of the youth or adult criminal justice process for committing an offense or delinquent act, OR do you have trouble obtaining or keeping a job because of an arrest or conviction? *

Yes

No

Do you currently attend school (including college or technical education)?

Yes

No

Are you working toward a GED?

Yes

No

Do you have a high school diploma or GED? *

Yes

No

Do you have a college degree or certificate? *

Yes

No

Do you have college work toward an unfinished certificate? *

Yes

No

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Start date

MM

DD

YYYY

End date

MM

DD

YYYY

Reason for leaving

Quit

Laid Off

Moved from Area

Fired

Other

Which best describes your current employment status? *

Check all that apply:

Employed working for wages, self-employed, or working 15+ hours per week unpaid in family business. ("Employed" includes if you are away from job because of vacation, leave, etc.)

Part-time (PT is less than 30 hrs/wk or considered PT by your employer)

Full-time

Self-Employed

Employed, but received termination notice from employer/military

Not employed (not working, but available for work and looking for work)

Exhausted Unemployment Benefits, and don't have an appropriate job

Have been unemployed for 27 or more consecutive weeks, but have been looking for work and was available for work during the entire time

Not in labor force (not employed and have not actively been looking for work)

Do you or a family member currently receive (or received in the last 6 months) any of the following?

Check all that apply:

SNAP

TEA

Work Pays

Supplemental Security Income (SSI)

Are you within 2 years of exhausting your lifetime TANF eligibility? *

Yes

No

Do you certify that all the income sources above are all the sources of income for your family? *

Yes

No

Check any of the following that you think may apply to you:

A homeless individual (lack a fixed, regular, and adequate nighttime residence)

A runaway (under the age of 18 and has left home without the permission of your parents/guardians

In foster care, aged out of foster care, or attained the age of 16 and left foster care for kinship guardianship or adoption or an out-of-home placement

Single Pregnant female or a parenting male or female (custodial or non-custodial)

Non-single pregnant female or a parenting male or female (custodial or non-custodial)

Face cultural barriers to employment because your beliefs, customs, or practices serve as a hindrance to employment

I authorize the local provider of WIOA Title 1-B Adult and Dislocated Worker Programs (hereafter called WIOA) to use the information in this application to help me reach my goals. I also authorize them to exchange pertinent personal information with other service providers as appropriate to help meet my needs and reach my goals. I understand that all exchanged information shall remain private and confidential in accordance with the confidentiality policies of each agency receiving and sharing information. *

Yes

I authorize the Social Security Administration, the Arkansas Department of Workforce Services, the Arkansas Department of Human Services, the Arkansas Department Career Services, the Arkansas Department of Higher Education, the Arkansas Department of Corrections, the local and state police and sheriff departments, appropriate WIOA One-Stop partners, employers (past and present), educational entities, and other appropriate WIOA entities to share with WIOA information that can help me establish eligibility for services, reach my goals, and document my successes. Information shared may include, but is not limited to, information that could help me become eligible for appropriate programs; assessments; benefits received from SNAP, TANF, Social Security, SSI, and/or Unemployment Insurance; grants, scholarships, and loans received for training; grades, attendance records, and credentials for training or work experiences provided by (or for which supportive services are provided by) WIOA, and other information that could help me meet my goals and document my outcomes. *

Yes

I agree to hold harmless the Arkansas Workforce Center, the Local Workforce Development Board, WIOA, or entities releasing information to WIOA, for information released according to the confidentiality guidelines of such agencies. *

Yes

I agree that a copy of this authorization may be used as an original. *

Yes

This authorization shall continue for one (1) year from the date of exit from the WIOA program or until such time that WIOA is notified in writing by the applicant that the authorization is canceled. *

Yes

I understand that submission of this application and/or eligibility determination does not guarantee enrollment. *

Yes

I certify that I have read and fully understand all questions asked on this application, and that I should ask for clarifications if needed before I sign this application. *

Yes

I certify this information to be true to the best of my knowledge, and there is no intent to commit fraud. I am aware that if I am found ineligible after starting the program, I will not be allowed to continue in the program. I am also aware that legal action may be taken against me if it is found that I knowingly provided false or fraudulent documentation during the eligibility process. *

Yes

Date *

MM

DD

YYYY

Date

MM

DD

YYYY