Youth Services Interest Form

*submit youth information only* This form is to be completed for youth program only.

WorkSource Atlanta Youth R.I.S.E. Program provides exposure and opportunities as it relates to skills and employment for youth ages 14-24. These services are offered year-round based on availability of funds on a first-come first-served basis. Youth must be eligible in order to participate in WIOA youth activities. To learn more, check out our 14 elements.

Please complete the short form below if you have questions about our program.

Name *

First

Last

Age

Selected Value: 14

Date of Birth *

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Phone *

Last School Grade Completed *

What is the last grade you completed/passed in school? (eg. 5th grade)

Current School Grade *

What grade are you currently in?

We help individuals with the following barriers:

• Basic skills deficient (GPA 2.0 or lower)
• An English language learner
• A justice-involved- individual
• A homeless individual or runaway
• An individual in foster care or who has aged out of the foster care system or who has attained 16 years of age and left foster care for kinship guardianship or adoption, a child eligible for assistance under Section 477 of the Social Security Act, or in an out-of-home placement
• Pregnant or parenting (custodial and non-custodial parent including noncustodial fathers)
• An individual with a disability

Check all that apply

Are you interested in receiving these services? *

• Employment/Work
• Going back to school
• Help with school

Check all that apply

Have you held a job before where you received a paycheck? *

• yes
• no

Submit