HIRE L.A. 18-24
YOUTH REGISTRATION APPLICATION

* = required fields


Contact Information

*Name:

*Address: *City: *Zip:

*Telephone: Cell Phone: *E-mail:

*Enrolling Organization:

Background Information
Personal Information
*Date of Birth: Age: *Gender: Male Female

Social Security Number: Enrollment Date [Today's Date]:

*Educational Background:
Are you currently attending school?
If so, the Name of the School:

Are you out of school? What was the highest grade you completed:

*Employment Background
Never Been Employed Before
Previously Employed by Summer Youth Program [SYETP]
Previously Employed in the Private Sector

*Please Select Areas of Interest for Employment
Administrative [clerical]
Construction
Entertainment
Food Service
Financial
General Service
Medical
Retail
Other

Opportunities

Participation Opportunities:

I would like to attend a WRC Session:
Date: Location:

I would like more information about Job Skills Workshops

Optional Information

Race/Ethnicity [Select one or more]
American Indian or Alaska Native Asian Black or African American
Hispanic or Latino Native Hawaiian or Pacific Islander White
Other


Citizenship
U.S. Citizen Eligible, Non-Citizen [A# ] Ineligible, Non-Citizen


Selective Service Registrant [Military]
Yes No Not Required

Disabled
Yes, Barrier Yes, No Barrier No

Check Any or All That Apply
Pregnant or Parenting Youth
Homeless
Receiving School Lunch
Family or Self Receiving Food Stamps
Family or Self Receiving Temporary Aid for Needy Families [TANF]
Family or Self Receiving General Assistance [GA]
Family or Self Receiving Supplemental Security Income [SSI]
Family or Self Receiving Refugee Cash Assistance [RCA]
City Council District

Comments or Questions