SOS Application - ULSTL

314-615-3600

1408 N. Kingshighway Blvd. - Saint Louis, Missouri 63113

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What We Do
Special Events
Social Media & Shop
- Social Media
- Urban Closet Store
Get Involved
COVID-19
- Employee COVID-19
- Mask Intake Form

Save Our Sons Application

* Indicates required field

Save Our Sons City or County *

St. Louis City St. Louis County

Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Did you participate in the program last year? *

Yes No

Would you like to volunteer for Save Our Sons *

Yes No

What type of job are you interested in? *

Cook Construction Warehouse Healthcare Office Work Driving Custodial Open

Phone Number *

Date of Birth *

Gender *

Male Female

Referral Source *

Flyer Social Media Agency Website Word of Mouth

Phone Number *

Age *

Ethnicity *

Black/African American White Asian American Indian/Alaskan Native Black/African American & White Nat. Hawaiian/Other Pacific Islander Am. Indian/Alaskan Nat & White Asian & Black Asian & White Other Multi‐Racial

What brought you to Save Our Sons (SOS)? *

What are your immediate needs? *

EMPLOYMENT AND EDUCATIONAL GOAL

Short-term Educational Goals *

Short-term Employment Goals *

Long-term Educational Goals *

Long-term Employment Goals *

Health (as appropriate)

1. Do you have any disabilities? *

Yes No

2. Are you receiving government assistance? *

Yes No

3. Do you have health insurance? *

Yes No

4. Have you ever been treated or referred for emotional problems? *

Yes No

5. Do you recreationally use drug or alcohol? *

Yes No

6. Do you feel that you have any emotional difficulties? *

Yes No

6a. If yes, would you talk to a professional? *

Yes No

7. Do you feel that drugs and/or alcohol are having a negative effect on your life? *

Yes No

8. Have you ever received treatment/counseling for drug or alcohol use? *

Yes No

9. Would you like help with drug or alcohol use? *

Yes No

Legal Issues

1. Have you ever been convicted of a felony? *

Yes No

Do you have any legal issues pending? *

Yes No

FAMILY INCOME:
PLEASE NOTE:  Income includes wages, salaries, tips; self-employment or business income; unemployment & disability income; retirement & insurance income; public assistance;  interest and dividend income; alimony; child support; gift income; and armed forces income for all family members 18 years of age and older. Each family member over the age of 18 with income will be required to submit a Source of Income Documentation Form (and the related attachments).

FAMILY INCOME TABLE (BELOW):
Enter in the number of persons in your family.  Family Size includes children (0-17 years old) and adults (18+years old).
Then enter in your family annual Income category.  Family Income must include income for all adults in family.

Family Size *

Family Annual Income *

Authorization to Release Information
CERTIFICATION: (Please read before signing) this organization is supported with Federal funding.
According to Title 18, Section 1001 of the U.S.Code, it is a felony for any person to knowingly and willingly make false or fraudulent statement to any dep artment of the United States Government. By signing this Document, I certify under penalty of perjury, that all the information on this application is corr ect to the best of my knowledge and belief, and I acknowledge that such information is subject to verification. I also acknowledge that my failure to prov ide necessary documents within areasonable period of time or falsification of this information shall be grounds for my termination from the program. I authorize the release of said information to the City of St. Louis and state and federal agencies.

I am currently receiving services through the Urban League Save Our Sons Program. I understand this is a program that helps to improve employability skills & development. The services include education options, mentoring, leadership development, and career development. Additional services for employability skills include, career exploration which help to increase awareness for long term success. Counseling and guidance services will also be provided for the purposes of completing both your Objective Assessment and Individual Service Strategy. The following information must be secured on all Save Our Sons participants:

Attendance
Verification of Employment
Social/Supportive Service needs
Date of birth
Proof of Residency/Income
Other work related documents

I consent to the releasing of the above information to the Urban League by signing on the line below. I understand this information is required for any person to qualify for participation in this program.  I understand that this document will be valid for the next five (5) years from the date signed

Client Confidentiality: I understand that the information collected for the Save our Sons program will be used only to assist me and will not be shared with any 3rd parties. I also understand that individuals working at the Urban League and with me will only release information to me.

Photo Release and Story Form: I do hereby grant permission to the Urban League of Metropolitan St. Louis, Inc. Save Our Sons (SOS) Program to use images taken during my participation with the Urban League. Such use includes display, distribution, publications, transmission or other use of photographs or images and/or videos taken of me for use in materials that include but may not be limited to printed materials such as brochures and newsletters, video and digital images such as those on the Urban League website.I grant permission to use my images in print, video and digital media.  I agree that these images may be used by Urban League Save Our Sons (SOS) for a variety of purposes and that these images may be used without further notification to me.  I do understand that my last name will not be used in conjunction with any video or digital images.

Signature (Enter Full Name) *

Date *

I agree to receiving marketing and promotional materials

Submit

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