JOB ASSIST STUDENT/YOUNG ADULT APPLICATION

You may either download and mail the application or complete the form online. Youth under age 18 must provide their parent/guardian's contact information so we can receive verbal permission for you to participate in this program.

Student/Young Adult Application

First Name *
Last Name *
School District
School District Where You Reside
School
Current Grade
If no longer in school, please type "NA"
Date of Birth
/
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Age
Country
Address Line 1 *
City *
State/Province *
Postal Code *
Home Phone
If you don't have a home phone, please type "NA"
Cell Phone
If you don't have a cell phone, please type "NA"
Parent/Guardian Name(s)
If you are age 18 or older, names are not required. Please type "N/A."
Parent/Guardian Phone
Driver's License
Do you have a valid NYS Driver's License?
Working Papers
Do you have working papers?
Transportation
Do you have access to transportation?
Mode of Transportation
Ethnicity
For funding purposes, please indicate ethnicity.
Choose which job categories interest you.
Do you have any special certifications or trainings that would be applicable to a job?
Do you have any special skills or hobbies?
Please type your full name to sign.
Date
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YOUTH UNDER 18:  Please note that a Job Assist Coordinator will reach out to your parent/guardian to receive verbal permission for you to participate in the Job Assist Program.