Y Achievers Interest Survey
This form is for those interested in applying for the Y Achievers Program: a career workforce program that assists young adults ages 16-24 with their career and educational pursuits. If you have any additional questions regarding Y Achievers or the enrollment process contact Stacey Ramirez (sramirez@vosymca.org) or Joshua Barocio (josh.barocio@vosymca.org).
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Email *
First name *
Last name *
Age *
Gender *
Ex: male, female, non-binary, etc
Zip code *
Ethnicity or Race *
Required
If "Native American" was selected, please indicate your tribe
Please list all family who live with you. List their age, and relationship to you. If you are 18 or older, only list yourself, your spouse, or any dependents. *
Ex: Sara Molina (21, Self), Jack Thompson (22, Spouse), Xavier Thompson (6mo, Child)
What is the combined yearly income of the people listed above? *
What languages are spoken in your household? *
Please select the demographics that apply to you. *
Required
Are you currently attending school? *
What is the name of the current school you attend? If none, insert the name of the last school you attended. *
Last grade completed *
Last year you attended school? *
Reason for leaving last school *
How did you hear about the Y Achievers? *
Address *
Format: 4444 N. Cactus Rd. Phoenix, AZ 85602
Parent/Guardian phone number
Format: (XXX) XXX-XXXX
Social security number *
Format: XXX-XX-XXXX
Phone number *
Format: (XXX) XXX-XXXX
Email address *
Date of birth *
MM
/
DD
/
YYYY
Employed in the last 6 months? *
Insert the name of your last/current employer (from the past 6 months). If none, leave blank.
Approximate weekly hours. If none, insert "0" *
Date hired
MM
/
DD
/
YYYY
How would you rate your interest in attending college/trade school? *
Not interested
Highly interested
List your top career choice *
List your second career choice *
Besides yourself, who encourages you to do well in school? *
List anything that might keep you from attending college? Finances, transportation, lack of motivation etc. *
If you are currently in high school or in a GED program, how confident are you that you will receive your diploma/certificate.
Very doubtful
Very confident
Clear selection
Do you have any barriers to employment or education? (Check all that apply) *
Required
Select any public assistance you receive, if any.
Do you have any known medical problems? *
If selected "Yes" please specify
Do you have any hospital preferences? *
If selected "Yes" please specify
Please list 2-3 people as emergency contact. Include their name, relationship to you, phone number, and address. *
Format: Cesar Molina (brother, 602-399-3999, 4567 E. Roundabout Rd.), Salma Torres (mother, 602-400-4000, 4567 E. Roundabout Rd.)
Have you worked full time for at least 90 consecutive calendar days in the last 6 months for one employer? *
Do you have a written letter of recommendation from a previous employer? *
Have you been fired from any job or quit a job without cause? *
Do you have work experience (where training was provided) in either of the career choices you listed above? *
Did you successfully complete training and receive a certificate (or any credential) from the training? *
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