Exit Youth Work Experience Contact Information Form Question Title * 1. Name Question Title * 2. Address (Street, City, State, Zip) Question Title * 3. Phone Number Question Title * 4. Email Address Question Title * 5. Are you between the ages of 18-24? Yes No Question Title * 6. Are you authorized to work in the United States? Yes No Question Title * 7. If you are Male and 18 years of age, are you registered for Selective Service? Yes No Not Applicable Question Title * 8. Are you attending school (ex. Parkland College, University of Illinois Urbana-Champaign)? Yes No Question Title * 9. Do any of the following apply to you? Check all that apply. A high school drop out Recipient of a high school diploma Currently receiving SNAP and/or TANF benefits Subject to the adult or juvenile justice system Pregnant or Parenting Homeless, runaway, or foster youth Disabled Currently employed Question Title * 10. What industry are you interested in? Ag Tech Business Services Construction Healthcare Logistics Manufacturing Done