TRRC Stimulus Youth Questionnaire Name * First Date Address * City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Home Phone * Cell Phone Email * Date of Birth * SNN * In order that we may identify eligibility for special services and funding please answer the following: Do you have a disability? * Yes No If Yes, choose one: Temporary Permanent This information is helpful in supplying customer needs; however, you are not required to provide an answer. Please answer all questions that apply to you. Are you currently attending? (select all that apply) High School GED Classes Alternative School College Vocational School Do you have a high school diploma? Yes No Are you a special education student? Yes No Family income information TANF Food Stamps Other: Employment Are you currently registered with Illinois Skills Match? Yes No Are you currently Employed? Yes No Last or current employment: Where Hrs / Week Wage Personal Information What Skills do you have? What Interests and/or hobbies? Please check the type of assistance you are seeking Work Experience: Summer or in-school employment opportunities directly linked to academic and occupational learning. Tutoring: Study skills training and instruction leading to secondary school completion including dropout prevention strategies. Mentoring: Peer mentoring which may include activities such as positive social behavior decision making and team work. Work Readiness Training: Attending workshops and/or classes to learn job skills. Dual Credit: Financial assistance with dual credit courses. Vocational TRNG: Financial assistance with college courses. Specify course of study on line below. Other Course of Study Are you a former JTPA or Workforce Investment customer? Yes No PLEASE NOTE THAT ALL INFORMATION GIVEN IS CONFIDENTIAL. reCAPTCHA If you are human, leave this field blank.