Skip to main content
Resources
Get Help
Give Help
News & Events
Email Signup
Facebook
Twitter
Youtube
Donate
Lincoln
Project Everlast Lincoln
Central access
Opportunity Passport
Youth voice
Permanency Services
Transitional Services
Needs-Based Fund
Omaha
Program Overview
Youth voice
Central access
Education & Career Pathways
Opportunity Passport
Permanency Services
Transitional Services
Need-Based Fund
Councils
Project Everlast councils
Governor's Youth Advisory Council
Current Opportunities
Youth and Young Adult Social Media Influencer application
Probation Youth Council
Lincoln
Project Everlast Lincoln
Central access
Opportunity Passport
Youth voice
Permanency Services
Transitional Services
Needs-Based Fund
Omaha
Program Overview
Youth voice
Central access
Education & Career Pathways
Opportunity Passport
Permanency Services
Transitional Services
Need-Based Fund
Councils
Project Everlast councils
Governor's Youth Advisory Council
Current Opportunities
Youth and Young Adult Social Media Influencer application
Probation Youth Council
Donate
Youth First Name and Middle Initial (Required)
Youth Last Name (Required)
Today's Date (Required)
How can we help?
I am here for
(check all that apply)
Opportunity Passport
Need-Based Fund
Youth Leadership
Other supportive services
Check your most important needs below
(check all that apply)
Education
Physical Health
Transportation
Employment
Mental Health
Legal Documents
Housing
Substance Use
Supportive Relationships
Finances
Dentist
Other
Other
Current services and supports
I am currently receiving the following services and supports
(check all that apply)
Opportunity Passport
Bridge to Independence Services
Employment Services
Family Finding Services
Medical Services
Dental Services
Need Based Fund (in the past 12 mo.)
Other Indep. Living/Life Skills Services
Education Services (e.g. ETV, GED, tutoring)
Transportation Services (e.g. IntelliRide)
Mental Health Services
Credit Repair Services
Youth Leadership Council
Housing Services
Mentoring Services
Food Services (e.g. local pantries)
Substance Use Services
Legal Services
Other
Other
I am currently receiving the following types of public assistance
(check all that apply)
Medicaid
Childcare Subsidy/Title XX
Housing Voucher/Section 8
Food Stamps (SNAP)
SSI/SSDI
TANF
Aid to Dependent Children
WIC
Unemployment
Other
Other
A few questions about you…
Phone Number (Required)
Email Address (Required)
jzoz127wy003
Birth Date (Required)
Last 4 digits of SSN (Required)
Current/Mailing Address (Required)
City (Required)
State (Required)
County (Required)
Zip Code (Required)
Did you move to NE from another state?
No
Yes
Which state?
What is your gender?
Woman
Man
Another gender
Prefer not to say
What is your race/ethnicity?
(check all that apply)
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Prefer not to say
Other
Other
Are you part of a federally recognized tribe?
Yes
No
Review and Submit
The youth who this form applies has verified that this information is true and correct, and consents to have this information shared with appropriate serve providers.
YES, I consent.
NO, I do not consent.
For minors, this form requires approval from an NFC/DHHS caseworker.
YES, I consent as this young person's caseworker
NO, I do not consent.
