ACT Enrollment Form -

Enrollee Profile Information - Step 1 of 11

Thank you for completing the Advancing Communities Together enrollment form. Follow the instructions for each of the sections in the form to ensure accuracy and thoroughness.

Name *

First

Last

Address Information

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Gender *

Male
Female

What are your preferred pronouns?

Home Phone *

Work Phone

Email *

Date of Birth *

Mobile Phone

Program Information

Program Applying For: *

Anticipated Start Date *

Demographic Information

What is your race/ethnicity?

What is Your Marital Status? *

Are you authorized to work in the US? *

Are You a US Citizen? *

What is Your Monthly Household Income?

Do You Have Children? *

Number of Children *

Do Your Children Live With You? *

Do You Receive Child Support?

What language is spoken at home?

The demographic/miscellaneous information that Advancing Communities Together (ACT) collects is important for program placement and funding. This information is important for all applicants entering our program.

Drivers License *

Are You Registered to Vote? *

Have you registered with Selective Services? *

I am currently living with (Check all that apply) *

parent/guardian
spouse and/or children
alone with friends
in a homeless shelter
in a work/release program

Have you ever been in foster care? *

Have either of your parents ever been incarcerated? *

Have you ever been convicted of a crime? *

Describe the charge, the date, and the status of the case *

Do you have any active court cases? *

What was the charge? *

Are you on probation or parole?

Probation
Parole
Both
Not on Probation or Parole

Probation/Parole Officer Name / Phone Number *

First

Last

Probation / Parole Officer Phone

Barriers to Program Attendance

Note: Barriers to program attendance could make it difficult to attend the program every day.

Examples of this could be: Lack of reliable transportation, a need for child care, etc. Please Note: Depending upon the barrier, ACT may be able to provide or refer you to the support you need.

Please list barriers to attendance *

Have you taken any vocational or construction education? *

Vocational or Construction Education Description *

Have you taken any machine shop classes?

Machine Shop Classes Description *

Have you taken any training programs? *

Training Programs Description *

Have you NOT completed any training programs? *

Training Programs Completed Description *

Ever Been Employed *

Employment History - Job 1

Start Date

End Date

Employer Name

Ref 1 Phone

Address Information

Address Line 1

Address Line 2

City

State

Zip Code

Hourly Wage/Salary

Supervisor Name

Duties Description

Reason for Leaving

Ref 1 Employer Contact

Employment History - Job 2

Ref 2 Start Date

Ref 2 End Date

Ref 2 Employer Name

Ref 2 Phone Number

Ref 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Ref 2 Hourly Wage/Salary

Ref 2 Supervisor Name

Ref 2 Duties Description

Ref 2 Reason for Leaving

Ref 2 Employer Contact

Employment History - Job 3

Ref 3 Start Date

Ref 3 End Date

Ref 3 Employer Name

Ref 3 Phone Number

Ref 3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Ref 3 Hourly Wage/Salary

Ref 3 Supervisor Name

Ref 3 Duties Description

Ref 3 Reason for Leaving

Ref 3 Employer Contact

Employment History - Job 4

Ref 4 Start Date

Ref 4 End Date

Ref 4 Employer Name

Ref 4 Phone Number

Ref 3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Ref 4 Hourly Wage/Salary

Ref 4 Supervisor Name

Ref 4 Duties Description

Ref 4 Reason for Leaving

Ref 4 Employer Contact

Job Skills (Please Select All that Apply)

Do you have experience or skills in any of the following? Please check all that apply: *

Plumbing
Electrical Wiring
Drywall
Sheet Metal
Roofing
Power Tools
Web Design
Lift Truck
Painting
Mechanical Repair
Housing Rehabilitation
Rough Carpentry
Finish Carpentry
CAD Equipment
Personal Computer
Excel
MS Word
PowerPoint

How comfortable are you using a computer? *

List any other tools/machines you have operated

Do you have any physical, medical or other health problems? *

Do you have any physical, medical or other health problems (including allergies) that would affect your ability to do the physical activities needed to perform construction work?

Please describe your physical, medical or other health problems. *

Do you have Medicaid insurance? *

Do you have a fear of heights? *

Do you have diabetes? *

Are you able to bend down, stoop, and stand? *

Do you have a heart related issues? (Irregular heartbeat, etc.) *

Do you smoke? *

Do you have any lifting restrictions? *

Are you required to wear eyeglasses/contacts? *

Do you have any lifting restrictions? *

When was your most recent physical?

Please describe your latest physical *

How did you hear about our program? *

Explain why you want to participate in our program? *

What are you good at? *

How do you stay motivated during the 36 weeks of hard work? *

How will you get to the program every day? *

Describe your experiences working outdoors? *

Are you willing and able to participate in all construction activities? *

Note: Some programs involve physical labor sometimes in extreme weather conditions.

If No, Why Not? (Construction Activities) *

Do you agree to participate in all activities inside/outside of the classroom? *

Note: All programs include a variety of learning activities.

If No, Why Not? (Classroom Activities) *

Emergency Contact 1

Name *

Relationship *

Phone Number *

Emergency Contact 2

Name *

Relationship *

Phone Number *

Are you receiving financial benefits such as food assistance, subsidized housing or other?

Financial Benefits Explanation

Please list the financial benefits you are receiving.

No Income Certification

If you have a job or if you collect government funds (Cal-WORKS, SSI, SDI, etc, do NOT fill out this form

I, do hereby certify that I do NOT receive income from ANY of the following sources below.

I understand sources of income include, but are not limited to the following:

Checkboxes

Employment
Unemployment
Compensation
Social Security
Grants/Work Study
Child Support
Self-Employed
General Relief (GR)
Disability
Alimony
Income from Assets
Pensions
CaIWorks
Union Benefits

Financial Information Certification

I certify that the foregoing information is true, complete and correct. Inquiries may be made to verify
statements herein.
l also understand that false statements or omissions are grounds for disqualification from Antelope
Valley YouthBuild.

Signature *

Clear Signature

Authorization for Release of Information

I, authorize the exchange of educational, medical, psychosocial and/or social service information
between the AV YouthBuild and the individual(s) or agency(ies) listed below.

This authorization will be valid for 24 months from the date of signature or until revoked in writing
prior to that date.
I have the right to be informed about what information will be released.
I have the right to limit or specify; the information that will be released.
I understand that AV YouthBuild needs this information in order to assist me in completing my goals and receiving the services I need.

I understand that confidentiality cannot be maintained in the event of suspected child abuse or the
threat of-destructive behavior towards me or others and that, in such an instance, AV YouthBuild
staff working with me is mandated by law to report this.

Name of individual or agency releasing/receiving information:

Please complete the information below in the following format:

Please List (individual or agency): Antelope Valley YouthBuild
Contact Person: Cristina Palma, Enrollment Specialist
Phone Number: 661.266.8900
Email Address: enrollment@act4avyouth.org

Contact Person or Agency 1:

Individual or Agency 1

Contact Name and Title 1

Contact Person Phone 1

Email 1

Contact Person or Agency 2:

Individual or Agency 2

Contact Name and Title 2

Contact Person Phone 2

Email 2

Contact Person or Agency 3:

Individual or Agency 3

Contact Name and Title 3

Contact Person Phone 3

Email 3

Attendance Policy

All trainees are required to attend Education and/or Vocational Instruction Monday through Friday. Friday
Leadership classes are an integral part of AV YouthBuild and a graduation requirement. In the event of illness, doctor appointment, emergency, court appearance, and any and all other absences, the following
procedure must be followed in order for an "excused absence" status to be granted:

1. The trainee must make a personal phone call to the desk of the AV YouthBuild. Registrar/Attendance Monitor 661-266-8900. All calls must be made prior to 8:30 am the day the absence will occur. An explanation must be given to the person who answers the phone, including how long the trainee will be out and the reason for the absence. In the event that no one- answers, full details must be left on the voicemail. Please leave a voice mail message if no staff is available: clearly state your name, the reason for your absence and a phone number where you can be reached.

2. The staff member who takes a message concerning an absence will log that message into the telephone call log or database, being sure to include the date, time of the message and an accurate of the conversation.

3. All calls should be made to the front desk of the AV YouthBuild Registrar/ Attendance Monitor in addition to your assigned advisor.

4. Documentation must be presented when the trainee returns to AV Youthbuild. In the event of an illness, a note from a family member will be acceptable. If documentation is not presented to the Registrar/ Attendance Monitor on the day of return to the program, the absence will be counted as unexcused.

5. A trainee is subject to being self-selected out from AV YouthBuild if the trainee has three or - more unexcused consecutive absences and/or trainee attendance is low. Please communicate any attendance issues with a staff member, AV YouthBuild is willing to work with you.

I have read the attendance policy and agree to comply with it.

Attendance Policy Initials *

Dress Code Policy

Appearance is often thought of as one of the outward signs or indications by which a person or thing is assessed. We at AVYB and its members have established a culture of respect for learning in hopes of empowering all members toward achieving their personal and career goals. In doing so, it is required that all members be in dress code at all times. Failure to respect this dress code will result in not being allowed to participate in the program until they are appropriately dressed.

*We agree that uniforms are a plus.We agree not to wear gang attire.
*We agree with no short clothing. Shorts should be to t*e knees. No cut off shorts.
*We agree to not expose our midriff, chest area or wear tank tops or low cut blouses.
*We agree on no hats of any kind (except YouthBuild hats) on campus (including hoods).
*We agree to wear our pants at our waists.
*We agree to not wear clothing that is excessively baggy.
*We agree that if you are breaking the dress code, you will get verbal constructive reminders before hat is confiscated for the day.
*We agree that if we are out of dress code, we may be sent home immediately or not allowed on
campus after check-in.
*We agree that blue jeans will not have holes or slits exposing skin.
*We agree not to wear open-toe shoes or high heels (unless special event attire is accepted).

I have read the dress code policy and agree to comply with it.

Dress Code Policy Initials *

Drug Test and Random Search Policy

Please be advised that YOU ARE SUBJECT TO RANDOM SEARCHES at the discretion of the AV
YouthBuild Staff. POSSESSION OF CONTRABAND OF ANY SORT WILL BE RESULT IN TERMINATION PER
THE MEMBER'S MANUAL. Failure to comply with a request to search your person may result in a request
in a request to have a law enforcement officer-search you.

The RANDOM SEARCH POLICY is not designed to invade your privacy or accuse you of wrongdoing.
Random searches will be conducted to maintain the integrity of the YouthBuild program and ensure that
all YouthBuild members and staff have a safe and drug-free workplace.

Please review the DRUG-FREE WORKPLACE policy listed below:

Although AV YouthBuild is not a drug rehabilitation program, we have a policy of maintaining Drug-Free
Workplace and Environment'' In order to be an effective leader and to be successful in the workplace, in
institutions of higher learning, and in life, members must be clean and sober. All members are tested for
illegal drugs within the first month of the program. You may elect to waive any test, which is an admission
to drug usage and will be placed on a Level I Contract. You may be randomly drug tested throughout the
program.

I have read the Drug Test and Random Search Policy and agree to comply with it.

Drug Test and Random Search Policy Initials *

Photo and/or Video Tape Authorization

I hereby authorize staff for AV YouthBuild to do the following:

Authorize AV Staff (Check All that Apply):

Photography of Myself
Video or Myself
Photography of my child(ren)
Video of my child(ren)

The photograph(s)/video(s) may be used for the purpose of (Select All that Apply):

Member Charts
Website
Social Media
Text Message
Press Release
Public Relations
Publicity
Poster / Flyer
Commercial
Picture Mural
Video / Film
Brochure
No Restrictions Apply