Impact Wednesday

Avenue Youth House Application

Avenue Youth House is a program of Impact KCK that provides short-term and long-term opportunities for female high school students (16+) and young adults (18-24) looking to achieve self-sufficiency and achieve their goals. We are not an emergency, drop-in shelter. Our on-site case management Navigators work closely with the McKinney-Vento Liaison of all four Wyandotte County school districts to ensure our residents are moving forward on a pathway to career, education, and permanent housing. Participants must be willing to be employed, work with a navigator on life-skills, and explore educational/vocational opportunities.

Upon completion of the application below, Avenue Youth House staff will review the application and confer with the McKinney-Vento Liaison of the applicant's district (if applicant is a high school student) before reaching out to setup a meeting with the applicant.

Application

General Information

* Indicates required field

Applicant Name *

First

Last

Social Security Number last 4 digits (Enter 0000 if you prefer not to answer or do not know your SS#) *

Date of Birth *

Age *

Gender *

Marital Status (single, married, domestic partner, divorced, separated, widowed) *

Where are you living right now (house/apt, friends, relatives, shelter, hotel, street, car, other)? *

Phone Number *

Email *

Alternative means of contact (Facebook, Instagram, etc.) *

Best way to contact you *

Text Call Email Social Media

Address (Enter "N/A" if living on the street) *

Line 1

Line 2

City

State

Zip Code

Country

How long have you been staying at the above address? *

How many people live at the above address? *

Where do you sleep (couch, bed, floor, other)? *

Have you ever applied to this program? *

How did you hear about Avenue Youth House? *

Do you know anyone who has been in the Avenue Youth House program? *

What are your reasons for applying to the Avenue Youth House? *

Have you ever been in any other independent living program? (Examples include Hillcrest, ReStart, Synergy) *

Why did you leave that program? *

Are you currently working with a case manager? *

Yes No

Case Manager's Name *

First

Last

Case Manager's Phone Number *

Case Manager's Email *

Do we have your permission to contact your case manager? *

Yes No

Education

Are you currently enrolled in a school in Wyandotte County? *

What school do you attend? *

Select level of education completed *

If some high school, what was the last grade completed? *

Please enter all the schools you attended (Level - High School, GED, College, Trade, and Name of School) *

Please describe any problems you have had in school *

Family Information

Please list your family members (name, age, phone number, relationship) *

Parent/Guardian 1 Name *

First

Last

Parent/Guardian 1 Address (Enter "N/A" if unknown) *

Line 1

Line 2

City

State

Zip Code

Country

Parent/Guardian 2 Name *

First

Last

Parent/Guardian 2 Address (Enter "N/A" if unknown) *

Line 1

Line 2

City

State

Zip Code

Country

Children

Do you have children? *

List all children who are living with you (name, relationship, date of birth, age, type of custody) *

Emergency Contacts (name, phone, relationship) *

Health Information

Are you pregnant? *

Health concerns/problems *

Medications *

Name of physician *

Do you have allergies/dietary restrictions? *

Are you concerned about sexually transmitted diseases? *

Legal

Have you ever been arrested (DWI, bad checks, assaults, etc.)? *

Have you ever served time in jail or juvenile detention? *

Do you have pending tickets (speeding, parking, etc.)? *

Do you have any warrants? *

Are you currently on parole, probation, or diversion? *

Parole/Probation officer *

Parole/Probation officer phone number *

Counseling

Have you ever been in counseling? *

Have you ever been in a mental health hospital? *

Have you ever been in a drug or alcohol program? *

Are you an AA participant? *

Are you an NA participant? *

Life Skills

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on HYGIENE? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on HOUSEHOLD CHORES? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on WAKING UP ON YOUR OWN? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on LAUNDRY? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on BEING ON TIME? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on GETTING ALONG WITH OTHERS? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on PURCHASING FOOD? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on BUDGETING MONEY? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on PREPARING WELL BALANCED MEALS? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on PURCHASING CLOTHING? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on TAKING CARE OF OTHERS? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on USING BANKS? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on FINDING JOBS? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on HOLDING JOBS? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on USING PUBLIC TRANSPORTATION? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on USING HOSPITALS? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on USING THE LIBRARY? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on KNOWLEDGE OF COLLEGES? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on USING COMPUTERS? *

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself on USING TELEPHONES? *

How do you deal with anger? *

How do you deal with peer pressure? *

How do you deal with authority figures? *

What do you do with your free time? *

What do you do when you are alone? *

What are your hobbies? *

Transportation

Would you be willing to use public transportation/city bus system? *

Do you have a valid driver's license? *

Do you have a car? *

Questions/Comments

Let us know if you have any questions about the Program, or further comments on any sections of the applications *

By filling in my name below, I attest that everything entered above is true to the best of my knowledge *

First

Last

Submit

Avenue Youth House Application

Application

General Information

Education

Family Information

Children

Health Information

Legal

Counseling

Life Skills

Transportation

Questions/Comments

Equipping Center

Business Training Center

Donate

Volunteer