Riverside County Youth Opportunities Centers Program Application

Complete in black or blue ink. Pencil applications are not acceptable. The information on this application is necessary to determine your eligibility for the program. Please print and fill out this application completely.
Last Name First Middle / Social Security Number / Birth Date
Street Address (residence, do not use P.O. Box) / City / State
Zip / E-mail address
Mailing Address (if different) / City / State
Zip / Telephone
( )
Citizenship (check one)
 Us Citizen  Registered Alien
INS Alien Document / Have you registered for Selective Service?
 Yes  No
 Not required (Females) / Gender
 Male
 Female / Cell Phone/Message #
( )
( )
Refugee Number______
 Other Legal Alien Expiration Date______/ Number in Family
(Include yourself) / # of Your Dependents
(exclude yourself)
Check all that apply:
 Limited English
 School Dropout
 Gang Affiliation /  Foster Youth
 Offender
 Homeless/Runaway /  Physically Disabled
 Special Education
 Substance Abuse / Applicant and Family Sources of Income in the past 6 months (check all that apply)
 Wages
 Disability
 Workers Comp.
 TANF /  Food Stamps
 SSA/SSI
 Unemployment Ins.
 Other______
Are you attending school?
 Yes  No  Graduated HS/GED / If yes, what school are you attending and what grade are you in now?
Grade
Names, relationship, and age of family members in your household. (Example: Mary Smith (Mom 35)
EMPLOYMENT HISTORY Have you worked in the last 6 months? No  Yes If yes, complete all that apply below.
Employer Name, Address, City, State, Zip / Area Code &
Phone Number / Employed
From (M/D/YR.) / Employed
To
(M/D/YR.) / Job Title / Hourly Wage / Hrs. Per Week / Reason for Leaving
VOLUNTEER WORK Have you done any volunteer work? No YesIf yes, complete all that apply below.
Employer Name, Address, City, State, Zip / Area Code &
Phone Number / Employed
From (M/D/YR.) / Employed
To
(M/D/YR.) / Job Title / Hours per Week
I certify under penalty of perjury all the above information is true and complete. I agree any information I have given is subject to verification. I understand falsification of any item is grounds for termination from the WIA program and may result in an action to recover any monies paid to me while in the program. My signature also means I have received a copy of the Nondiscrimination, Equal Opportunity, and the Formal Grievance Notification forms.
SIGNATURE OF CLIENTDATE

Youth 448-25 04/07/10 js)