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 Apply for WIA Youth

Personal Information

First Name:
Last Name:
Age:
Address:
City:
E-mail:
Telephone Number:
Referred By:


Educational Information

Attending High School
Dropped Out
High School Graduate/GED
Attending Post-High School Institution


Financial Information (One of the following must be checked in order to qualify)

Economically Disadvantaged
      Household Size:
      Annual Income:
Received Food Stamps in the Last 6 Months
Currently in Foster Care
Diagnosed Disability (Learning, Physical, Mental):


Priority Points (Youth must have a MINIMUM of 4 POINTS to qualify)

Check all that apply:

(4 points) High School Graduate/GED or High School Drop-Out
(4 points) Foster Child or Emancipated
(4 points) Offender
(4 points) Migrant Youth
(4 points) Native American
(4 points) Child of Incarcerated Parent
(3 points) Pregnant or parenting
(2 points) Victim/Witness of Domestic Violence or Victim of Other Abuse
(2 points) Substance Abuse
(2 points) Basic Skills Deficient
(2 points) School Dropout
(2 points) Homeless/Runaway
(1 point) Chronic Behavior Problems at School
(1 point) Family Illiteracy
(1 point) Limited English Proficiency
(1 point) Lacks Occupational Goals/Skills
(1 point) Chronic Health Problems Including Disabilities