2018 Young Adult Employment Program Application
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- Belinda Webster
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1 2018 Young Adult Employment Program Application The Young Adult Program receives state and federal funding to provide employment and training opportunities to low income and/or at-risk youth ages that have graduated with their high school diploma/ged or have dropped out of high school. Please review the eligibility guidelines attached. The Young Adult Program provides career assessments and planning, post-secondary planning and financial assistance for training, opportunities to have a paid-work experience in a worksite in Washington County, job search assistance, financial assistance for job-related expenses along with referrals to community resources. Job sites include schools, libraries, government agencies, non-profit or community-serving organizations and limited private businesses. Jobs typically include clerical, custodial, child care, customer service or outdoor landscape work. Youth workers will earn $9.65 per hour covered by the Federal Fair Labor Standards Act. Youth must be able to follow directions, work independently and provide their own transportation to work. Applications will be reviewed for eligibility once received. Youth will be required to attend an orientation session and a training session covering workplace rules and expectations before placement in a job. Additional required workshops will be offered throughout the summer. The following are required with your application for eligibility and payroll: 1. Copy of social security card 2. Photo ID (passport, school ID, state ID or drivers license) 3. Proof of birth (passport, birth certificate, state ID or drivers license) 4. Math and reading grade level equivalents if you are unable to provide this information from a school, you will be required to take a math and reading assessment 5. Verification of disability if applicable The application must be complete and the items above must be included in order to be considered for participation in the Youth Program. Mail completed applications to: Attn: Youth Program Washington County Workforce Center 2150 Radio Drive Woodbury, MN Contact WFC Youth Program at wfcyouthprogram@co.washington.mn.us, or Minnesota Ready 711 with questions Cottage Grove Ravine Parkway S Cottage Grove, MN Phone: Fax: Forest Lake Forest Road N Forest Lake, MN Phone: Fax: Government Center nd Street North P.O. Box 6 Stillwater, MN Phone: Fax: Woodbury Service Center 2150 Radio Drive Woodbury, MN Phone: Fax: Equal Employment Opportunity / Affirmative Action We are an equal opportunity employer/program provider. Auxiliary aids and services are available upon request to individuals with disabilities
2 Eligibility Guidelines Youth must meet all of the following three requirements: Not less than age 16 and not more than age 24 (graduated high school, received GED or currently working on GED with Adult Basic Education) Income Level: Family Size Maximum Income 1 $12,140 2 $16,460 3 $20,780 4 $25,100 5 $29,420 Under current guidelines, a youth with a documented disability, homeless, pregnant or parenting, or subject to the justice system will be considered a family of one and only the income of the youth will be considered. An individual who has one or more of the following risk factors: o Deficient in basic literacy skills o School dropout o Homeless, runaway or foster child o Pregnant or teen parent o Offender o Individual who requires additional assistance to complete an educational program, or to secure and hold employment. o Youth with a disability - including physical, mental, emotional or learning disabilities Proof of risk factor can be supplied by school official, social worker, probation officer, doctor or counselor on the Verification Form attached to the Youth Program application. All males 18 and older must be registered with the Selective Service before submitting an application to work in our government-funded program. You may register at We are an equal opportunity employer/program provider Auxiliary aids and services are available upon request to individuals with disabilities. Keep this page and return the following application
3 MN WORKFORCE CENTER WASHINGTON COUNTY 2150 Radio Drive Woodbury, MN (651) Minnesota Relay 711 YOUNG ADULT PROGRAM APPLICATION IDENTIFICATION INFORMATION Last Name: First Name: MI: Social Security # Street Address: Apt: City/State/Zip: Home Phone: ( ) Address: Alternate Contact (other than home phone) Name: Relationship: Phone: ( ) DEMOGRAPHIC INFORMATION Date of Birth: / / Age: Male Female FAMILY STATUS (check one) Parent in 1-parent family (Sole custodial support for one or more children at home under age 18) Parent in 2-parent family (Share custodial support for one or more dependent children living at home) Living with your family who provides more than 50% of your support Living with your family providing more than 50% of you own support Living on your own RACE/ETHNIC STATUS (check all that apply) Caucasian (White) African American Asian American Indian/Alaskan Native (including South or Central American) Hawaiian Native or other Pacific Islander ETHNICITY Hispanic or Latino I am of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture origin. Yes No VETERANS STATUS (check one) I served in the active U.S. military, naval or air service for a period of less than or equal to 180 days, and was discharged under conditions other than dishonorable. I served in the active U.S. military, naval or air service for a period of greater than 180 days. Neither situation above applies. ELIGIBILITY INFORMATION CITIZENSHIP STATUS (check one) U.S. citizen or naturalized citizen of the United States Eligible non-citizen/permanent resident alien Neither situation above applies SELECTIVE SERVICE (check one) I am registered. Registration # Required to register, but not yet registered Neither situation above applies 1
4 FAMILY SIZE What is the total number of persons living in your household who are related by blood, marriage or adoption? (This should be the maximum number at any time during the last six months including stepchildren or stepparents.) ANNUALIZED INCOME List ALL before-tax (gross) income during the last six months. Include income from ALL family members. Family member name (include your name) Relationship to you Date of Birth Type of Income Past 6 months total income amt. Self TOTAL FOR PAST SIX MONTHS: $ FOR OFFICE USE ONLY: TOTAL ANNUALIZED INCOME: $ FINANCIAL ASSISTANCE My family does not receive any public assistance. My family does receive the following types of assistance: Social Security Type General Assistance Refugee Assistance Food Support MFIP/DWP MFIP = MN Family Investment Program / DWP=Diversionary Work Program FOSTER CHILD I am a foster child on whose behalf state or local (county) government payments are being made. Does not apply LIMITED ENGLISH PROFICIENCY English is not my native language, and it is difficult for me to communicate in English. Does not apply DISABILITY STATUS I have a physical, mental, learning, emotional/behavioral disability, or history of substance abuse that DOES NOT make it hard to get or keep a job. I have a physical, mental, learning, emotional/behavioral disability, or history of substance abuse that DOES make it hard to get or keep a job. Neither situation above applies PARENTING/PREGNANT YOUTH I am age 24 or under with responsibility to support dependent children or I am now pregnant. Yes No RUNAWAY YOUTH I am 24 years of age or less, living away from home without permission of parent(s) or legal guardian. Yes No HOMELESS I do not have a fixed, regular and adequate nighttime residence. Yes No OFFENDER I have been arrested or convicted; OR been involved with the courts, probation or a diversion program Yes No RECOVERING CHEMICALLY DEPENDENT I have previously used or abused alcohol/drugs AND am not presently using or abusing alcohol/drugs, but past use/abuse has caused a problem with school or work. Yes No 2
5 EDUCATION INFORMATION HIGHEST GRADE COMPLETED Include high school, GED, vocational/technical, military, college or other. School Attended Dates Attended Highest Grade Completed Degree or Certificate Area of Study EDUCATION STATUS AT APPLICATION (check all that apply) Enrolled and attending junior high or high school full-time OR part-time Enrolled and attending an ALC/ALP or GED program full-time OR part-time High school graduate and am having difficulty finding work High school graduate and am not having difficulty finding work High school dropout Student attending post-secondary school Do you have an Individualized Education Plan (IEP)? Yes No If so, who is your case manager? PELL GRANT RECIPIENT Are you receiving, or have you been notified that you will be receiving a Pell Grant? Yes No EMPLOYMENT INFORMATION LABOR FORCE STATUS (select one) In the last 7 days I was: Employed Full-time Worked as a paid employee for 31 hours or more per week Employed Part-time Worked 30 hours or less per week Previously self-employed non-farm Self-employed in last job (not as a farmer or rancher) and am now not employed, or am in the process of going out of business due to general economic conditions, natural disasters, fire or other catastrophe Previously self-employed farm Self-employed as a farmer or rancher but not now employed, or in the process of going out of business as a result of general economic conditions or because of natural disasters, fire or other catastrophe Not Employed Not meeting the above definitions, or underemployed and not previously self-employed SIGNIFICANT WORK HISTORY During the past 2 years, I have worked for the same employer for longer than 3 months in a row. Yes No 3
6 UNEMPLOYMENT INSURANCE STATUS Eligible Claimant I have filed a claim and have been determined eligible; or I am receiving benefit payments and have not exhausted benefit rights or have not come to the end of the benefit year. Exhausted I have exhausted UI benefits. Ineligible but with Labor Force Attachment I was working but didn t earn enough to be eligible for UI, or I worked for an employer who was not covered under a state unemployment compensation law. Eligible Non-Claimant I have not filed an unemployment claim, but would be eligible to receive benefits if I filed a claim Not Applicable None of the above applies. # OF WEEKS UNEMPLOYED How many weeks of the last 26 weeks (6 ½ months) have you not worked? weeks LAST HOURLY WAGE If employed during the last 26 weeks, what was your hourly wage? $ per hour LAST JOB TITLE If employed during the last 26 weeks, what was your job title? WORK HISTORY (Start with most recent employment) DATES EMPLOYED EMPLOYER S NAME & ADDRESS WORK EXPERIENCE From: Month Year Name Job Title / To: Month Year City/State Responsibilities/Tasks Performed / Wage/Hr # Hrs/Wk Reason for Leaving DATES EMPLOYED EMPLOYER S NAME & ADDRESS WORK EXPERIENCE From: Month Year Name Job Title / To: Month Year City/State Responsibilities/Tasks Performed / Wage/Hr # Hrs/Wk Reason for Leaving 4
7 YOUNG ADULT PROGRAM ASSESSMENT Jobs that may be available: Select, in order, your job selections. Put a 1 by the job that suits you best, 2 by your second choice, etc. Skills: Interests: Janitor or Custodian s Helper cleaning in school or public building Outdoor Maintenance cutting grass, planting, park upkeep Teachers/Recreational Aide working with children in daycare and/or summer recreation Clerical/Office Aide answering phones, filing, typing, receptionist-type duties, etc. Thrift Store stocking, organizing, cleaning Library shelving, organizing Food Service fast food, bakery, cafeteria Do you have a driver s license? Yes No How will you get to work? Car Bus Bike Walk Other Work days/hours available: Mon Tues Wed Thurs Fri Sat Sun Will you be taking classes or workshops? Yes No If yes, what days/hours? Do you have any physical conditions that limit the type of work you can perform? Yes No If yes, please explain Any other conditions/situations that could limit or affect your ability to work? Yes No If yes, please explain What 2 or 3 things could prevent you from taking or keeping a job? I certify that the information provided is true to the best of my knowledge. I am also aware that the information I have provided is subject to review and verification and I may have to provide documents to support this application. I am also aware that I am subject to immediate termination if I am found ineligible after enrollment and may be prosecuted for fraud and/or perjury. I allow release of this information for verification purposes in accordance with the use of data statement. Applicant Signature Parent/Guardian Signature (if applicant is under 18) Workforce Center Staff Signature / / Date / / Date / / Date We are an equal opportunity employer/program provider. Auxiliary aids and services are available upon request to individuals with disabilities. 5
8 6
9 VERIFICATION FORM This form is to be completed by a school or agency staff person (teacher, counselor, probation officer, ESL Instructor, social worker, doctor) who can verify that the youth applicant qualifies for one of these categories. It is not to be completed by the applicant. Please check the categories that apply to this youth that you can verify according to your records. For verification purposes, this form cannot be completed by a parent or guardian. Name of Applicant Birth date / / Age Do your records verify this applicant s birth date? Yes No Physical Disability (type) Mental Disability (type) Learning Disability (type) Emotional Disability (type) Assessed as chemically dependent Foster Child Homeless or Runaway Youth Limited English Proficiency Actual School Dropout Teen Parent or pregnant female Experiencing personal or academic difficulty Potential dropout, or dropped out and returned to school Youth Offender or participant in diversion programs Youth with basic skills deficiency (at or below 8.0 grade level) Youth with an IEP Individualized Education Plan Receives public assistance, group home services, or free meals Youth with educational attainment one or more levels below grade level appropriate to age Verified by: Title & Agency: Date: Phone: I hereby certify that is currently/was previously enrolled at: Name of student (Name of School) Grade level of Reading Test Name and Date: Grade level of Mathematics Test Name and Date: Signature of School Official / / Date 7
10 Washington County WFC Young Adult Program Participant Media Release Form Washington County WorkForce Center Young Adult Program may photograph or record video of participants and projects for the purpose of promoting its program, showing the impact of WFCYP on the community and recognizing the accomplishments of participants. Photos and/or video may be used in brochures, fliers, newsletters, annual reports and other materials, s and other avenues. WFCYP partners as well as representatives of the media (newspapers, magazines, radio, television, etc.) sometimes request permission to use WFCYP photos and/or video in their coverage of WC s programs, participants and projects. If you are 18 or over, please complete this section: Please initial one of the following options: I grant permission to WFCYP to use my likeness in photos and/or video and/or my name in any and all of WFCYP print or video materials to promote WC and its programs and/or to recognize my accomplishments. I grant permission to WFCYP to provide my name and/or photos and video that may include my likeness to partners and media representatives to promote WC and its programs and/or to recognize my accomplishments. I waive the right to inspect or approve any specific use of my image and/or name. - OR I do not grant permission to WFCYP to use my likeness or name. Participant Name (printed): Participant Signature: Program: Date: If you are under 18, please have your parent/guardian complete this section: Please initial one of the following options: I grant permission to WFCYP to use my child s likeness in photos and/or video and/or my child s name in any and all of WFCYP print materials to promote WC and its programs and/or to recognize my child s accomplishments. I grant permission to WFCYP to provide my child s name and/or photos and videos that include my child s likeness to partners and media representatives to promote WC and its programs and/or to recognize my child s accomplishments. I waive the right to inspect or approve any specific use of my child s image and/or name. - OR I do not grant permission to WFCYP to use my child s likeness or name. Participant Name (printed): Parent/Guardian Name (printed): Parent/Guardian Signature: Program: Date: 8
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