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Application - YouthBuild Greater Stark County
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How did you learn about Project REBUILD?
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My school
My probation officer
My parent or guardian
Someone that is a member there
Facebook or Website
Job Fair
A caseworker I work with
Ohio Means Jobs
A community event
You should know that we have a drug-free program and will do drug testing throughout the nine months you’re enrolled. You will be required to successfully pass a drug test within three weeks of starting Mental Toughness to be eligible for any incentives and formal enrollment. Do you understand what this means? If not, call the office at 330-588-3205, option #4 to discuss.
Yes
No
If someone specific referred you, what is their name?
Today's Date
Your Name
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First
Last
Address Line 1
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Address 2
City
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State
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Zip Code
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Phone
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2nd Phone
Email
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Your Date of Birth
Note that our program is limited to ages 16 to 24 at time of enrollment. If you have questions about this, please call 330-588-3205, ext 4
Check all that apply to you:
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I have had court involvement under the age of 18
I have had court involvement over the age of 18
One of my parents is incarcerated
I am a foster youth
I receive food or cash assistance
I am under the age of 18 and live with my family that receives food or cash assistance
Note: if none of these apply to you, please call the office at 330-588-3205, option #4 to discuss.
Your Gender
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Female
Male
Prefer not to answer
Your Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
Your Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
I am:
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Registered to Vote
Not eligible to Vote
Eligible to Vote but Not Registered
Are you registered with Selective Service?
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I am registered
I am a male, over the age of 18 but not registered
Not 18 yet
A female and not required to be registered
Note that we are required to register any male over the age of 18 if they are formally enrolled in our program.
I have a high school diploma or GED
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Yes
No
Note that by indicating "yes" and depending on current enrollment, you may not qualify for the program.
The last school I attended was:
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The last day I attended school was:
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I currently am living:
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With my parent(s) or legal guardian
In a foster home
On my own. I rent.
On my own. I own a place.
With friends.
In a shelter or transitional housing.
I am currently homeless.
Please share your household's current yearly income:
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$0-$5,000 per year
$5,001-$10,000 per year
$10,001-$15,000 per year
$5,001-$20,000 per year
$20,001-$25,000 per year
$25,001-$30,000 per year
$30,001-$35,000 per year
$35,001-$40,000 per year
over $40,000 per year
Are you a veteran?
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Yes
No
Are you the spouse of a veteran?
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Yes
No
Are you working right now?
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Yes
No
If you are working, where are you working?
Have you had a job in the past?
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Yes
No
What are some challenges you've had in the workplace in the past?
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What is your marital status?
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Single
Married
Divorced
Are you a parent?
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Yes
No
Are you currently on probation or parole?
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Yes
No
If you are on probation or parole, please provide a name and contact number for your probation or parole officer.
Do you have community service to complete?
Yes
No
If you answer yes, we are an approved Community Service site through the Canton Municipal Court. Talk to us because we can submit your unpaid Mental Toughness hours for credit.
File Upload - Your ID
Click or drag a file to this area to upload.
Note that we will require certain documents to verify eligibility and be formally enrolled. If you are not comfortable uploading documents here, please make arrangements to come to the office so that we can make copies in person.
File Upload - Your Social Security Card
Click or drag a file to this area to upload.
Note that we will require certain documents to verify eligibility and be formally enrolled. If you are not comfortable uploading documents here, please make arrangements to come to the office so that we can make copies in person.
File Upload - Your Birth Certificate
Click or drag a file to this area to upload.
Note that we will require certain documents to verify eligibility and be formally enrolled. If you are not comfortable uploading documents here, please make arrangements to come to the office so that we can make copies in person.
File Upload - Your Medical Card
Click or drag a file to this area to upload.
Note that we will require certain documents to verify eligibility and be formally enrolled. If you are not comfortable uploading documents here, please make arrangements to come to the office so that we can make copies in person.
File Upload - Your (or parent's) Food or Cash Assistance Card
Click or drag a file to this area to upload.
Note that we will require certain documents to verify eligibility and be formally enrolled. If you are not comfortable uploading documents here, please make arrangements to come to the office so that we can make copies in person.
File Upload - Your Diploma or Transcripts
Click or drag a file to this area to upload.
Note that we will require certain documents to verify eligibility and be formally enrolled. If you are not comfortable uploading documents here, please make arrangements to come to the office so that we can make copies in person.
Your Signature
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Clear Signature
By signing this application, you hereby state that the information provided on this document is true and current and understand that in addition to the information provided above, Project REBUILD may request additional information as required for verification purposes.
Signature of Parent or Guardian if you're under the age of 18
Clear Signature
Submit
