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SYEP Youth Application 2010

1. Date:

2. First Name:

3. Last Name:

4. Address:

5. City:

6. State:

7. Zip Code:

8. County:*

9. Phone Number:

10. Alternate Phone Number:

11. Email Address: (you must provide a valid email address to participate)

12. Do you have a Facebook, MySpace, or Twitter account where we can reach you? You must provide your email address or user name.

13. Date of Birth: Month *

14. Date of Birth: Day*

15. Date of Birth: Year*

16. Will you be between the ages of 16 and 24 on June 1, 2010?*

17. Please select the proof of age you will be able to provide-you must be no younger than 16 years old and no older than 24 years old as of June 1, 2009:*

18. Gender:*

19. Social Security Number:

20. Will you be able to provide a copy of your social security card?*

21. Have you ever participated in a Summer Youth Employment Program?*

22. If yes, when and where?

23. Have you ever been in the military?*

24. Citizenship:*

US Citizen

Registered Alien

Refugee

Other Legal Alien

Other Status

25. Please select the citizenship/right to work documentation which you will be able to provide:

26. Selective Service Registration:*

Registered

Not registered

Underage

Female

Other exemption

27. Please select one low income item which applies to you:*

A. Received, or is a member of a family that received a total family income, the 6 month period prior to application (not including unemployment compensation, child support payments, cash public assistance and old-age and survivors insurance benefits received under section 202 of the Social Security Act) that, in relation to family size, does not exceed the higher of the poverty line or 70% of the lower living standard income level

B. Receives, or is a member of a family that receives cash payments under a federal, state or local income-based public assistance program such as TANF

C. Receives, or is a member of a family that receives food stamps (or has been determined within the 6 month period prior to application to be eligible to receive food stamps)

D. Qualifies as a homeless individual

E. Foster child on behalf of whom state or local government payments are made

F. Is an individual with a disability whose personal income does not exceed the higher of the poverty line or 70% of the lower living standard income level (not counting family income)

28. If option A (total family income less than poverty or 70% LLSIL) above, please select the documentation which you will be able to provide for your entire family:

29. If option B (cash assistance) above, please select the documentation you will be able to provide:

30. If option C (food stamps) above, please select the documentation you will be able to provide:

31. If option D (homeless) above, please select the documentation which you will be able to provide:

Written statement from individual providing temporary residence using Residency Verification Form (Form 5-0706)

Written statement from homeless shelter

Written statement from social service agency

Client statement (only if primary nighttime residence is a public or private place not designed for, or ordinarily used as, a regular sleeping accomodation for human beings)

32. If option E (foster) above, please select the documentation which you will be able to provide:

33. If option F (disability) above, please select the documentation which you will be able to provide for your disability:

34. If option F (disability) above, please select the documentation which you will be able to provide for your personal income:

35. How many family members live in your household? (Family is defined as two or more persons related by blood, marriage or decree of court who are living in a single residence and are included in one or more of the following categories: 1. a husband, wife and dependent children; 2. a parent or guardian and dependent children; 3. a husband and wife)

36. Please select any of the documentation listed which you will be able to provide for family size verification:

Birth certificates

Decree of court

Divorce decree

Landlord statement or lease agreement

Marriage certificate

Most recent tax return listing all family members

Public assistance/social service records

Public Housing Authority records

Written statement from care facility or institution

Client statement (for a family size of one ONLY)

37. All SYEP clients must have one of the following barriers. Please select the one which you will use for enrollment:*

1. Basic Skills Deficient-defined as an individual who computes or solves problems, reads, writes or speaks English at or below grade level 8.9

2. Homeless or Runaway

3. Foster child

4. School dropout

5. Pregnant or parenting youth

6. Disability

7. Previously dropped out of an educational program

8. Missed 20 or more days of middle or high school within the last 12 months, excused or unexcused

9. Have a GPA below a 2.0

10. An individual who is 16 years or older who has no vocational/employment goal

11. An individual who is 16 years or older who has a poor or no work history

12. An individual who is 16 years or older who has been fired from a job in the last 6 months

13. An individual who has been subject to any stage of the criminal justice process

38. If option 1 (Basic Skills Deficient) above, please select the documentation which you will be able to provide: (CASAS testing is available for free at the Workforce Center)

39. If option 2 (homeless or runaway) above, please select the documentation which you will be able to provide:

Written statement from individual providing temporary residence using Residency Verification Form (Form 5-0706)

Written statement from homeless shelter

Written statement from social service agency

40. If option 3 (foster) above, please select the documentation which you will be able to provide:

41. If option 4 (school dropout) above, please select the documentation which you will be able to provide:

42. If option 5 (pregnant or parenting) above, please select the documentation which you will be able to provide:

43. If option 6 (disability) above, please select the documentation which you will be able to provide:

44. If option 7, 8, or 9 above, please select the documentation which you will be able to provide:

45. If option 10, 11, or 12 above, please select the documentation which you will be able to provide:

46. If option 13 (offender) above, please select the documentation which you will be able to provide:

47. Please indicate your current education status:

48. What is the highest grade level you have completed?

49. Do you or the people you currently live with receive any of the following types of assistance? (Mark all that apply)

TANF-Temporary Aid to Needy Families

Food stamps

Subsidized housing

Refugee assistance

SSI-Supplemental Security Income

None of the above

50. Have you ever been arrested?

51. If so, please explain:

52. Have you ever been adjudicated or convicted?

53. If so, please explain:

54. What is your primary language?

55. What other languages, if any, do you speak fluently?

56. I certify that the information provided in this application is true and correct to the best of my knowledge. I am aware this information is subject to review and verification, and that I may be required to provide additional information or documentation to receive services. I am also aware that I am subject to immediate termination from this program if I am found ineligible after enrollment and that I may be prosecuted for fraud and/or perjury if the information I have provided is false. I authorize the release of information contained in this application for purposes of verifying my eligibility for services and I understand that this information will not be released for any other purpose without my permission. I understand that my completion of this application and electronic submission of it via this website constitutes an electronic signature and is legally binding as such. I understand that if I am selected to participate in this program both myself, and my parent or legal guardian if I am under 18 years of age, will be required to sign additional documents in person prior to receiving any services. By entering my name here, I am providing an electronic signature:

57. Parent or legal guardian's name (if applicant under 18 years):

58. Parent or legal guardian's phone number (if applicant under 18 years):