WIOA Youth Prescreening Form

First Name*

Last Name*

Additional Eligibility Requirements*

Parent or pregnant

Homeless, foster care, and/or aged out

Ex-offender

Diagnosed with a mental or physical disability

Unemployed/currently receiving unemployment for last 3 years

Low income due to wages or public assistance in the last 6 months

If 25 and older, please fill out the form and check this box. We will refer you to the WIOA adult program

In addition to being between the ages of 16-24, authorized to work in the U.S., and registered for Selective Service (if assigned male at birth), you need to meet one or more of the criteria above.

Date of Birth*

Email*

Phone Number*

Spring 2026 Schedules Now Available

LDP

WIOA Youth Prescreening Form