YouthBuild Registration

Please have yourself or your guardian complete the following form as fully as possible to register for the next cohort.

What is your primary interest in participating in YouthBuild?

Studying for the GED *

True

False

Construction Training *

True

False

Customer Service Training *

True

False

First Name *

Last Name *

Today's Date: * +

Date of Birth * +

Demographic Information

Gender Identity and Preferred Pronouns

Female *

True

False

Male *

True

False

Non-Binary *

True

False

He/Him *

True

False

She/Her *

True

False

They/Them *

True

False

Racial/Ethnic Identity

Asian/Pacific Islander *

True

False

Black/African American *

True

False

Hispanic or Latino/a/x *

True

False

Native American *

True

False

White/Caucasian *

True

False

Other Racial/Ethnic Identity?

Contact Information

Street *

City *

State *

Zip/Postal Code *

Phone Number *

Email Address *

Preferred method of contact: *

Other Contact Method:

Parent/Guardian Information:

Name of Parent/Guardian

Parent/Guardian Phone Number

Parent/Guardian Email

Alternate Contact Information:

Alternate Contact Name

Relationship/connection to you:

Alternate Contact Phone

Alternate Contact Email

Which best describes your current housing arrangement: *

Education and Support Information

Are you currently in High School? *

True

False

If you are attending school, what is the name of the school?

Other School Name

Are you currently or have you ever been placed in foster care? *

True

False

Are there any specific accessibility needs our staff should be aware of? *

True

False

Are you considered to have refugee status/seeking asylum in the U.S.? *

True

False

Do you have any history with juvenile or criminal justice departments? *

True

False

Have you ever experienced homelessness? *

True

False

Do you receive any treatment for your mental health? *

True

False

Do you have any children or currently expecting a child? *

True

False

Are either of your parents/guardians currently incarcerated? *

True

False

Are you eligible for any of these services? (Check all that apply)

Food Assistance? *

Supplemental Security Income *

Cash Assistance *

Section 8 Housing *

Medicaid *

How did you hear about YouthBuild? *

If you have one or all of the following documents, please upload them at this time. Thank you.
Driver's License
Social Security Card
Birth Certificate
State ID

Anything else you want us to know?

Thank you for registering for the GRCCT YouthBuild Grand Rapids program.

Contact us with any questions at 616-254-7736 or youthservices@bethany.org

We look forward to connecting with you soon!