Member Application – Project REBUILD & YouthBuild Greater Stark County – Project REBUILD, Inc.

Member Application - Project REBUILD & YouthBuild Greater Stark County

Your Name *

First

Last

Today's Date

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

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

Email *

Please do not submit a school issued email address.

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.

How did you learn about Project REBUILD? *

My school
My probation officer
My parent or guardian
Someone that is a member there
Social Media (Facebook, Instagram, Snapchat, Tiktok)
Job Fair
A caseworker I work with
Ohio Means Jobs
A community event

If someone specific referred you, what is their name?

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
I am a minor (under the age of 18)
There are minor children in the household (under the age of 18)
None of the above apply

Note: if none of these apply to you, please call the office at 330-588-3205, option #4 to discuss.

Do you have *

A drivers license
A state ID
Need help getting your ID

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.

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

Your 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. *

By signing this, you are giving Project REBUILD the right to request additional information on your behalf. You understand that this is a cooperative effort by agencies involved to best meet your needs.

Signature of Parent or Guardian if you're under the age of 18

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