HOY Interest Form

To see if you pre-qualify for the HOY program, please fill out the following form to the best of your ability. An HOY staff person will contact you within 2 business days to notify you and see if you have any questions. All information is secure and confidential.

Contact Information

First Name:*
Middle Name:
Last Name:*
Street Address:*
City:*
State:*
Zip Code:*
Home Phone:
Cell Phone:
Email Address:
How did you hear about HOY?*

Demographic Information

Date of Birth:*
Gender:* male female

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Hispanic/Latino?* yes no

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Number of people in your household:*

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estimated total household income: *

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racial group:

Ctrl + Click to select multiple groups

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work authorization status: *

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selective service registration: *

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current employment status: *

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unemployment compensation programs: *

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last education level completed: *

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current education status: *

Assesment of Challenges to Employment/Education

To be eligible for WIA grant funded HOY services, youth must have at least 2 "barriers" to employment and/or education. Please answer the following questions to the best of your ability.

Is English your second language?*
yes no
Are you from a single parent home?*
yes no
Are you a single parent with primary responsibility for your child(ren)?*
yes no
Are you in foster care?*
yes no
Are you adopted?*
yes no
Are you currently homeless?*
yes no
Are you a runaway youth?*
yes no
Are you on probation?*
yes no

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Are you an offender?*
yes no
Are you pregnant or a parent?*
yes no
Do you have a drivers license?*
yes no
Do you have your own reliable transportation?*
yes no
Behind a grade level in school?*
yes no
Please list any additional barrier(s) you may have