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Step-Up WIOA Registration
This information is confidential and kept on a secure server.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Phone
*
Date of Birth
*
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Student ID #
*
Email
*
What is your total annual household income? If there is not any income, enter 0.
*
Includes income and assets of all household members over the age of 18 including students.
How many individuals live in your household that are under the age of 18?
*
How many individuals live in your household that are 18 or older?
*
Will you be attending summer school?
AM Session
AM Session
PM Session
Not Attending
Where did you complete your online application?
*
The head of household is:
*
Which session time would you prefer for your sessions for 9 week program? (we cannot guarantee a time but will take this into consideration)
*
AM Session
AM Session
PM Session
Would you prefer to be online or in person this summer?
Yes
Yes
No
In the event we must go virtual:
Do you have a tablet or computer to use for your 9 week program?
*
Yes
Yes
No
Do you have a smart phone to use for your 9 week program?
*
Yes
Yes
No
Will you have adequate wi-fi for a 4 hour session per day for the 9 weeks?
*
Yes
Yes
No
This employer or program has received federal funding assistance. Participation requires demographic information to be tracked however this information will only be used for purposes related to this request or program.
Does anyone in your household receive any of the following assistance? Please select Yes or No for each category.
Free and/or Reduced Lunch
*
Yes
No
Section 8
*
Yes
No
MFIP/TANF
*
Yes
No
Food Stamps
*
Yes
No
Foster Child Allowance
*
Yes
No
General Assistance
*
Yes
No
Child Support
*
Yes
No
SSI
*
Yes
No
Unemployment
*
Yes
No
Vet Disability
*
Yes
No
Other
*
Yes
No
Explain Other:
*
Income Verification (Free/Reduced Lunch Letter, Section 8 Letter, 2 recent paystubs, etc)
*
Click or drag a file to this area to upload.
Social Security Card
*
Click or drag a file to this area to upload.
Photo ID: School and State
*
Click or drag a file to this area to upload.
Birth Certificate or Age Verification Document from School
*
Click or drag a file to this area to upload.
Media Release (under 19)
Click or drag a file to this area to upload.
WIOA-Youth Document
Click or drag a file to this area to upload.
Age:
*
14-15
16+
I-9
*
Click or drag a file to this area to upload.
W-4
*
Click or drag a file to this area to upload.
W-9
*
Click or drag a file to this area to upload.
Attestation Form
*
Click or drag a file to this area to upload.
Photo Release Form
*
Click or drag a file to this area to upload.
Direct Deposit Form
*
Click or drag a file to this area to upload.
Authorization and Consent to Release Information
*
Click or drag a file to this area to upload.
By submitting this form, I agree to make my financial records available to the City of Omaha, its designee, or HUD for verification of above information. I certify that the information above is, to the best of my knowledge and belief, a true, correct and complete statement of my financial conditions as of the date stated herein. I am aware that Section 1001 of Title18 of the U.S. Code makes it a criminal offense to make false statements or misrepresentation to any Department or Agency of the U.S. as to matters within its jurisdiction.
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