M E M O R A N D U M
Youth name: _______________________________________ Sex: Male Female
Date of birth: ____/____/_____ Age:_____ SSN: ________________________________
Address: __________________________________________________________________________________
__________________________________________________________________________________________
Telephone number: (Home) ________________________ (Work) _______________________________
(Cell) _________________________________________ E-mail:_______________________________
Marital Status: Single Married Separated Divorced
Children: None One Two Three, or more
Name, address, telephone of adult providing emotional support (example, former foster parent or relative):
__________________________________________________________________________________________
EDUCATION: Completed high school/GED Enrolled in GED or vocational training
Attending college Other
Receiving tuition waiver? Yes No Receiving ETV? Yes No
Education Goals: ___________________________________________________________________________
EMPLOYMENT: Full time Part time Participating in job training/internship
Armed forces Unemployed Other
Employment Goals: _________________________________________________________________________
CURRENT HOUSING: Living alone Living with relatives Living with friends
Homeless Other
Housing Goal: ______________________________________________________________________________
HEALTH: Have health care problems/need healthcare Have health insurance Have past due medical bills Other
Health Goal: ______________________________________________________________________________
******************************************************************************************
What aftercare service are you requesting from Baltimore City Department of Social Services?
**********************************************************************************
FINANCIAL ASSISTANCE: BGE turn-off Telephone turn-off notice Other
Water bill Emergency clothing & personal items
Explain: __________________________________________________________________________________
__________________________________________________________________________________________
HOUSING ASSISTANCE: Eviction notice Rent/Room & Board Other
Security deposit Household Items/Furniture
Explain: __________________________________________________________________________________
__________________________________________________________________________________________
EMPLOYMENT ASSISTANCE: Job readiness/Enhancement training Job search Other
Explain: __________________________________________________________________________________
__________________________________________________________________________________________
EDUCATIONAL ASSISTANCE: GED Enrollment College enrollment FAFSA Other
College tuition waiver information College prep exams
Explain: __________________________________________________________________________________
__________________________________________________________________________________________
OTHER SUPPORTS: Substance abuse or addiction referrals Parenting
Mental health referrals Food
Day care referral and assistance Obtaining Social Security card
Obtaining medical insurance or care Obtaining birth certificate
Community support/mentoring Obtaining driver's license/ID
Budgeting/other independent living skills Other
Explain: __________________________________________________________________________________
__________________________________________________________________________________________
******************************************************************************************
Youth's Signature: ______________________________________________ Date: _____________
Independent Living Coordinator: ______________________________________ Date: _____________
******************************************************************************************
TO BE COMPLETED BY IL COORDINATOR:
Date of Closing:__________ Date of Opening: ______________ Case #: _______________________
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BALTIMORE CITY DEPARTMENT of SOCIAL SERVICES
3007 East Biddle Street
Baltimore, Maryland 21213
AFTERCARE SERVICES APPLICATION FORM
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