Youth Conservation Corps Member Application YCC Member Application If you are human, leave this field blank. Your First Name * Your Last Name * Email Address * Mobile Phone Number * Home Phone Number * Address * City, State, Zip * Date of Birth (MM/DD/YYYY) Example: 01/01/2000 Sex * Male Female Do you have a valid Social Security Number (SSN)? * Yes No Do you currently receive any government assistance? Yes No If yes, what kind (i.e. housing, food stamps, etc)? What type of housing best applies to you? * Public Housing Homeowner Renting Shelter Homeless Who do you live with? Parents Other Family Alone Roommates Spouse/Partner Race/Ethnicity Black / African American Hispanic / Latino White / Caucasian Native American Other Last School Attended Last Grade Attended 7th Grade 8th Grade 9th Freshman 10th Sophomore 11th Junior 12th Senior Last Year Attended 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 Have you received a high school diploma? * Yes No If you didn't finish high school, why not? Have you completed the GED Program? Yes No If no, what GED tests have you completed? Do you have a valid driver's license? Yes No Have you held a job before? Yes No Are you currently working? Yes No If yes, hourly rate? If yes, hours per week? Name of Company Start Date End Date Job Title Duties Are you now on probation * Yes No If yes, what is your Probation Officer's name? If yes, what is your Probation Officer's phone number? Are you currently on parole? Yes No If yes, what is your Parole Officer's name? If yes, what is your Parole Officer's phone number? If any, please list scheduled or pending courts dates How did you hear about YCC? What is the size of your household (the number of persons currently living together in your home, including yourself ) What is your estimated annual household income? $0-$13,400 $13,400-$26,800 26,900-$40,210 $40,210-$53,620 $53,620-$67,020 $67,020+ I certify that the above information is true and correct to the best of my knowledge. * Yes Due to the current public health concerns, do you agree to do a “virtual interview” (YCC is currently using Zoom)? * Yes No Do you agree to have your interview recorded so that staff may view it at a later time? * Yes No Do you have a current driver’s license, state-issued ID card (not high school) or passport? * Yes No What is the expiration date of your identification (month/day/year)? Do you have a computer (laptop, desktop, Chromebook)? * Yes No Does your computer (laptop, desktop, Chromebook) have a camera & microphone? * Yes No Do you have internet access in the location where you would participate in the YCC Program? * Yes No Are you interested in learning more about earning industry-recognized Information Technology (IT) certifications from CompTIA Yes No reCAPTCHA Submit
