YCC YouthBuild Application YCC Member Application Your Name (First, Middle, Last) * Email Address * Home Phone Number * Mobile Phone Number * Address * City, State, Zip * Your age and date of birth * 16 17 18 19 20 21 22 23 24 Month * Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year * 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Sex * Male Female Do you have a valid Social Security Number (SSN)? * Yes No Emergency Contact Person (name) * Emergency Contact Email Address * Emergency Contact Phone Number * Do you currently receive any government assistance? * Yes No If yes, what kind (i.e., housing, food stamps, etc)? What type of housing best applies to you. * Public Housing Own Your Home Renting Shelter Homeless Who do you live with * Parents Other Family Alone Roommates Spouse/Partner Race/Ethnicity * Black / African American Hispanic / Latino White / Caucasian Native American Other Last School Attended * Last Grade Attended * 7th Grade 8th Grade 9th Freshman 10th Sophomore 11th Junior 12th Senior Last Year Attended * 2010 2011 2012 2013 2014 2015 2016 2017 Do you receive a high school diploma? * Yes No If you did not finish high school, why not? Have you completed the GED Program? * Yes No If no, what GED tests have you completed? Do you have a valid driver's license? * Yes No Have you held a job before? * Yes (please complete the following fields about your job(s)) No (skip past the next questions) Are you currently working? * Yes No If yes, hourly rate? If yes, hours per week? Name of Company Start Date End Date Job Title Duties Are you now on probation ? * Yes No Probation Officer Contact Number Are you currently on parole? * Yes No Parole Officer Contact Number Please list any scheduled or pending court dates Are you taking any medications? * Yes No If you are taking an medications, please list them here How did you hear about YCC? I certify that the above information is true and correct to the best of my knowledge * Yes reCAPTCHA Youth Conservation Corps does not discriminate on the basis of race, color, sex, sexual orientation, religion, creed, national origin, age, veteran status or disability unrelated to job requirements. YCC is a drug-free work and training place.