Summer Cadre Eligibility Form Summer Cadre Program Eligibility Form Application Eligibility Date MM slash DD slash YYYY Last 4 Digits of Your Social Security #(Required) CONTACT INFORMATIONName(Required) First Middle Initial Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Phone TypeLandlineMobileMay we send you text messages? Yes No Email(Required) DEMOGRAPHIC INFORMATIONDate of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleDisability(Required)YesNoNot ProvidedIf “Yes”, you will be required to complete a WIOA Disability Form at enrollmentAuthorized to Work in U.S.(Required)Citizen of the U.S.U.S. Permanent ResidentAlien/Refugee Lawfully Admitted to the U.S.If U.S. Permanent Resident or Alien/Refugee:Alien/Visa Registration #Expiration Date MM slash DD slash YYYY Hispanic Heritage(Required)YesNoNot ProvidedRace(Required)WhiteAfrican American/BlackAmerican Indian/AlaskanIndianPakistaniBangladeshSri LankanNepaleseSikkimeseBhutaneseJapaneseChineseKoreanMalaysianThaiLoatianCambodianVietnameseFilipinoOther AsianSamoanPalauanMicronesianGuamanianMarshalleseOther Pacific IslanderI do not wish to answerEMPLOYMENT INFORMATIONEmployment Status(Required)EmployedEmployed But Received Notice of Termination of Employment or MilitaryNot EmployedIf Employed, are you underemployed?YesNoUnemployment Insurance EligibilityNoClaimantExhausteeNumber of Weeks UnemployedCurrent/Previous Hourly RateOccupation EDUCATION INFORMATIONCurrently enrolled in school(Required)YesNoHighest Education Level(Required)Less than high schoolHigh school completionSome college or associate’s degreeBachelor’s degreeAdvanced degreeHigh School Diploma or Equivalent Received(Required)YesNoPUBLIC ASSISTANCETemporary Assistance for Needy Families (TANF) – Recipient(Required)ApplicantFamily MemberNot ApplicableSupplemental Security Income (SSI) - Recipient(Required)ApplicantFamily MemberNot ApplicableGeneral Assistance (GA)(Required)ApplicantFamily MemberNot ApplicableSupplemental Nutrition Assistance Program (SNAP)(Required)ApplicantFamily MemberNot ApplicableSocial Security Disability Insurance Income (SSDI)(Required)ApplicantFamily MemberNot ApplicableReceiving services under SNAP Employment & Training Program(Required)YesNoFoster Child (state or local payments are made for applicant)(Required)YesNoYouth currently living in high-poverty area(Required)YesNoBARRIERSEnglish Language Learner(Required)YesNoBasic Skills Deficient/Low Levels of Literacy(Required)YesNoHomeless(Required)YesNoEx-Offender – individual has been arrested/convicted of a crime(Required)YesNoSingle Parent (including single pregnant women)(Required)YesNoCultural Barriers(Required)YesNoFAMILY INCOMEFamily Size(Required)Past 6 months Family Income(Required)APPLICANT CERTIFICATION STATEMENTI certify that the information on this application is accurate to the best of my knowledge. I understand that my willful misstatement of the facts may cause my forfeiture of rights in the Summer Cadre Program and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for Summer Cadre. I further understand and agree that my social security number and other information on this application will be provided to other government agencies as required by law. Signature(Required)
