Page 1 of 3 Version 11/2020 Account #:
Application f
or Services
Carefully read Application Instructions on Page 1 BEFORE completing this application.
Wh
at service(s) are you applying for? (check all that apply)
Child Care Services
Youth Services
Higher Education Services
Employment and Training Services
Name:
Preferred or Community Name:
Tribal Enrollment #: Tribe Name:
Social Security Card or Social Insurance Card # (attach copy of card):
D.O.B.: Gender: Male Female Age:
How
would you prefer to be contacted? Phone E-mail Text Home Visit
Physical/Residential Address: Mailing Address:
County: Do you live in a rural area? Yes No
Primary Phone: Other Phone:
E-mail:
Emergency Contact Name and Contact Information:
Do you have a disability? Yes No
If yes, please name type of disability (physical, mental, and/or sensory):_________________________
Current Veteran Status:
Veteran Transitioning Service Member
Campaign Veteran Disabled Veteran
N/A
Current Marital Status:
Single Married Divorced Separated Widowed C
ommon Law
Cur
rent educational status:
In school, high school or less Not attending school, high school drop out
In school, post high school Not attending school, high school graduate
In school, alternative school
Current Employment Status:
Full time Part time Unemployed
Current Hourly Wage: $ _________________
First Name Last Name Middle Name
If you have already applied for
services in the last year, please call
518-358-9721 ext. 2275 to speak
with our Intake Coordinator.
