Webform

Please include the following items to your application:

- Parent/guardian income verification (a copy of '10 or '11 tax return or copies of last two months' pay stubs)
- A copy of your most recent high school transcripts (or verficiation of GPA)

Foster Youth: Please submit your own income statement for verification (if no income, indicate zero) and no signature required for guardian/parent areas.

Program Applying For: *

Youth's First Name: *

Youth's Middle Name:

Youth's Last Name: *

Gender *

Date of Birth: *

(mm/dd/yyyy)

Street Address: *

City: *

Zip Code: *

Home Phone #:

Cell Phone #:

Social Security #: *

Email: *

High School *

High School Cumulative GPA *

Juma Youth Referral

Have you ever at any time been a foster youth? *

Are you legally able to be employed in the U.S.? *

Do you qualify for Free or Reduced Lunch Program at your HS? *

Did either of your parents graduate from a 4-year college or university? *

Do you currently have a bank account? *

Availability

Juma is a fully inclusive program that focuses on college access, professional development, financial literacy and personal development. In order to be successful, we require you to be fully engaged in all aspects of the program. Can you commit to 4-6 workshops/meetings per month for the next 2 years to ensure your future success? *

Are you currently involved in any after-school activities that you will continue into the next years? (Please check all that apply) *

If other, please specify:

If so, how many hours per week do you spend on the above activities?

How many hours are you available to work each week during the school year? *

How many hours are you available to work each week during summer break? *

How many days per week are you available to meet in the Juma space? (Typically 1.5 hrs between 3:30-7pm) *

What are the best days for you to meet at the Juma office? Please check all that apply. *

Interest:
Please answer all three questions:

1. Tell us why you want to be a part of the Juma program.

(250 words or less)

2. If you were to get this job, how would it benefit you?

(250 words or less)

3. Tell us about a difficult situation that you were in and how you overcame it:

(250 words or less)

Emergency Contact

Name:

Relationship:

Phone:

Address:

Have you ever been convicted of a felony? *

If yes, please give dates and details:

*A conviction will not necessarily bar you from employment

1. I certify that the information contained on this application is correct to the best of my knowledge and understand that deliberate falsification of this information is grounds for dismissal in accordance with the policy of Juma Ventures.

2. I authorize the references listed above to give you any and all information concerning my previous employment and pertinent information they may have personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

3. I acknowledge that, if I become employed, I will be free to terminate my employment at any time for any reason and Juma Ventures retains the same rights. No Juma Ventures representative has the authority to make you any contrary agreement.

Your Name: *

Date:

(mm/dd/yyyy)

By checking this box, you are agreeing to the terms mentioned above. *

I Agree

ETHNICITY (REQUIRED). Please also make a selection from the "RACE" options in the next box. Please note that race is recorded for statistical purposes and will not affect your application chances.

Hispanic/Latino/a: *

Please check all that apply: *

If other, please specify:

Please Select The Appropriate Family Size & Income Level:

Please check here if your family income exceeds the income levels provided on the above chart.

I agree.

Thank you for your interest in Juma Ventures. Our mission is to get youth in and through college. Our program provides a job but is also a full educational program as well and if accepted to the program, it is our expectation that you fully engage in all aspects of it.

I acknowledge that I have read the above statement. *

I agree.