WIOA Youth Follow-Up FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. we WIOA can Your Name *FirstLastNY #Counselor Name *FirstLastWould you like to enroll in the WIOA Youth Follow-Up Services program? *YesNoWhat does YES mean? This means you would like to enroll in WIOA Youth Follow-up Services and maintain contact with the Youth Counselor throughout the next 12 months. By checking ‘Yes’, you will continue to receive approved assistance with work, training needs, and earn incentive cards. You can opt out of Follow-up Services at any time by notifying your Counselor. If your Counselor can’t get a hold of you, you might be removed from the program – so keep in touch!What does NO mean? This means you would NOT like to enroll in WIOA Youth Follow-up Services and maintain contact with the Youth Counselor throughout the next 12 months. By checking ‘No’ you will not be able to receive approved assistance with work and training related needs or earn incentive cards.Your Contact InformationPlease fill out all the information below so our records up to date, whether you want to be in the program or not. Sign and send it back as soon as you can!Phone *Phone Type *CellHouseOtherWhat type of phone do you have? *Voice Mail Set-up? *YesNoTexting OK? *YesNoEmail *How Often is Email Checked? *Mailing Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIf we can’t connect with you, who can we contact? (#1)Individual's Name *FirstLastRelationship to Youth *Individual's Phone *Voice Mail Set-up? *YesNoTexting OK? *YesNoIf we can’t connect with you, who can we contact? (#2)Individual's Name *FirstLastRelationship to Youth *Individual's Phone *Voice Mail Set-up? *YesNoTexting OK? *YesNoTraining/EducationAre you currently employed and/or pursuing further training or education?YesNoCurrent Employer InformationEmployer *Supervisor *Current Position *Work Phone *Start Date *Hours Per Week *Hourly Wage *Current Education/Training InformationProvider *Contact Person *Phone *Expected Start Date *Expected End Date *Type of School/Training *Hours Per Week *Think about the next 12 months…What employment or career goals would you like to focus on? *What education or training goals would you like to focus on? *Youth's Signature * Clear SignatureSubmit
