• OhioMeansJobs Warren County Youth Program Interest Form

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender assigned at birth:*
  • What is your ethnicity?*
  • Citizenship (check all that apply):*
  • What is your race? (check all that apply)*
  • Are you legally restricted from using a computer?*
  • Relationship Disclosure - Do you have a business or personal relationship with any individual who is a: Local elected official (mayor or county commissioner); Workforce Development Board member or subcommittee member; WIOA executive, supervisor or employee;OhioMeansJobs center partner employee, WIOA sub-recipient and/or contractor; or County employee?*
  • What is your education level:*
  • Do you have work experience in Agriculture within the last 12 months?*
  • What is your current education status?*
  • Have you served in the US Military?*
  • Are you a spouse of a veteran?*
  • Are you a homeless veteran?*
  • Do you hold a valid drivers license?*
  • Are you interested in an Apprenticeship?*
  • Have you registered for Selective Service (for individuals born male, 18 or older)?*
  • Are you enrolled in ASPIRE?*
  • Have you received OWF for one or more years?*
  • Have you taken a recent math/reading assessment?*
  • Do you use recreational drugs or drink regularly?*
  • Are you a single parent?*
  • Do you think you have a cultural barrier that might hinder employment?*
  • Are you homeless?*
  • Are you a public assistance recipient (cash/food)?*
  • Are you enrolled in Vocational Rehab through OOD?*
  • Are you receiving SNAP Employment and Training?*
  • Do you have a disability?*
  • Are you a runaway?*
  • If English is not your native or primary language, do you need help learning to speak/write/use English?*
  • Are you involved or were you involved in the juvenile court or adult justice system?*
  • Are you in foster care or were you previously in foster care?*
  • Are you pregnant?*
  • Are you a parent (including noncustodial)?*
  • Are you/have you received a Pell Grant?*
  • Is your family eligible to receive free/reduced-price lunch?*
  • If you are an in-school youth (i.e. attending high school or a post-secondary program), do not complete this section if you are homeless, a runaway, or a foster youth. If you are not attending school, only complete if your case manager requests you to do so. Please answer the following questions if you are 18 or older:*
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  • If you answered "yes" to any questions directly above, you are independent of a parent or guardian and only your income will be used to determine WIOA youth eligibility. 

  • Only complete the next section if you are attending school (high school or college/technical school) or your case manager asks you to. Including yourself, who is in your household? What is their relationship to you? What is their average monthly income? (Your case manager can let you know the timeframe to consider.) If you have a disability, only include your personal income.
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  • Have you or anyone you are living with been ordered to repay cash assistance (OWF), due to determination of fraud and still owe repayment?*
  • Are you currently receiving cash assistance?*
  • Are you currently receiving SNAP?*
  • Complete the table below indicating each household member's monthly income:
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  • Do you have a child under age 18 or is 18 who is attending high school full-time?*
  • Are you one of the following (check all that apply):*
  • Have you been given the opportunity to register to vote?*
  • Should be Empty: