Application – YouthBuild Greater Stark County

Your Name *

First

Last

Today's Date

How did you learn about Project REBUILD? *

If someone specific referred you, what is their name?

If you would like to have emails regarding the application process sent to another person such as a parent, guardian, teacher, probation officer please include their email here.

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

Address Line 1 *

Address 2

City *

State *

Zip Code *

Primary Phone *

Secondary Phone

Can we text you at either of the above numbers? If so, please indicate which phone number can receive texts

Email *

Please do not submit a school issued email address.

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: *

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 *

Female
Male
Prefer not to answer

What preferred gender pronouns should we use for you in our program?

He / Him
She / Her
They / Them

Your Ethnicity *

Hispanic or Latino
Not Hispanic or Latino

Your Race *

I am: *

Registered to Vote
Not eligible to Vote
Eligible to Vote but Not Registered

Are you registered with Selective Service? *

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 *

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: *

The last day I attended school was: *

I currently am living: *

Please share your household's current yearly income: *

Are you a veteran? *

Yes
No

Are you the spouse of a veteran? *

Yes
No

Are you working right now? *

Yes
No

If you are working, where are you working?

Have you had a job in the past? *

Yes
No

What are some challenges you've had in the workplace in the past? *

What is your marital status? *

Single
Married
Divorced

Are you a parent? *

Yes
No

Are you currently on probation or parole? *

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

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