2021-2022 JCG WIOA Pre-Application Form

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Get Involved
Who We Are
- Staff
- Board
- YP Board
News & Events
Contact Us
- Alumni

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What We Do
Get Involved
Who We Are
- Staff
- Board
- YP Board
News & Events
Contact Us
- Alumni

Menu

What We Do
Get Involved
Who We Are
- Staff
- Board
- YP Board
News & Events
Contact Us
- Alumni

Donate Today

School

First Name

Middle Name/Initial

Last Name

Birthdate

Age

Race

Hispanic

Street Address

Apt/Suit/Other

City

State

Zip

Phone

Mobile Phone

Email

Gender

US Citizen

Emergency Contact Name

Contact Number

Current Grade

Last Grade Completed

Are you registered to vote?

If no, have you been given the opportunity to register to vote?

Have you ever been employed?

Are you currently employed?

If yes, where?

Since when?

Have you been employed in the last 6 months?

If yes, where?

When?

Do you currently have a mentor?

If yes, with which agency?

What do you need assistance with / What services can JCG provide/connect you with?

Personal

Clothing Food Public Assistance In Foster Care; or previously in Foster Care Lack of Transportation Offender

Education

High School Diploma Graduation: Air Points SAT/ACT Prep College Information Financial Aid Tutoring School Fees Drivers Education Training

Health/Well Being

Counseling Medical Assistance Substance Abuse Issues Mentoring On current IEP plan Have a disability

Housing

Short-term Housing (Emergency shelter) Long-term Housing Homeless (current/previously) Runaway (current/previously)

Parenting

Pregnant Parenting Need Child Care

Employment

Career Exploration Job Training Job Better Job

Miscellaneous

Identification Documents Legal Assistance English Language Learner

Have you ever been enrolled with any of these agencies:

CYC: Mentoring CYC: AmeriCorps College Guides CYC: Talent Search Santa Maria Equus (formerly ResCare) CCMEPTalbert House

CCMEP Eligibility: Previous Six Months

Household Members: List Name and Relationship of each person who lives with you

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

Name

Relationship

Age if Sibling

Employed

Employer

If you are in Foster Care: where do you live?

Foster Parent: Name

Group Home: Name

Independent Living:

Do you/family receive OWF/FS/Public Assistance?

SSI/Disability Income?

Are you on an IEP or have a disability?

Are you behind a Grade Level?

Are you Pregnant/Parent?

Are you or have you ever been in Foster Care?

Have you ever been Arrested or thru the Court System?

Have you ever been Homeless/Runaway?

Have you previously enrolled in CCMEP (WIOA/TANF) programming?

Youth is potentially WIA Eligible

Interviewer Name

Date