South Central Workforce Investment Board SOUTHSIDE VIRGINIA COMMUNITY COLLEGE WIA YOUTH PROGRAM APPLICATION Items in bold/italics with a box require verification. Please check the box that verification is attached and indicate the form of verification. This application follows the format and language of the VOS application. ISY Program OSY Program (ISY School Case Manager ) (County Case Manager ) A. VOS INFORMATION: 1. Date Interviewer School 2. VOS User Name Password (3-20 Characters, letters or numbers) (4-16 Characters, letters or numbers) VOS Security Question: Who was your childhood hero? Security Question Response: Myself (Applicant can change password) 3. Social Security Number - - SS Card Verification Zip Code 4. Are you eligible to work in the United States? Yes No ------------------------------------------------------------------------------------------------------------------------------------------------------------------ B. CONTACT INFORMATION: 5. Name (First, Middle Initial, Last) 6. 911 Address 7. City State: Virginia Zip Code County Address Verification Recent letter from Social Service Agency Postmarked Mail/Bill Addressed to Applicant Driver s License School Record or Letter 8. Home Telephone Number Cell Number Alternate Number 9. Email Address 10. Mailing Address (If different from 911 Address): 11. City State: Virginia Zip Code County ------------------------------------------------------------------------------------------------------------------------------------------------------------------ C. PERSONAL INFORMATION: 12. Date of Birth / / Birth Certificate Verification Gender: Male Female Birth Certificate Number State 13. Have you registered for Selective Service? Yes No Not Applicable Verification Card Internet Records
14. Are you a citizen of the United States? Yes No Verification Birth Certificate Naturalization Certificate 15. Do you consider yourself to be of Hispanic heritage? Yes No Information Not Provided 16. Race (Select one or more): African American/Black American Indian/Alaskan Native Asian Hawaiian/Other Pacific Islander White I do not wish to answer 17. Do you consider yourself to have a disability? Yes No Verification School Records/IEP Social Security Records Medical Records Observable/Obvious with Witness 17. What can the W.I.A. assist you with? (Check all that apply) Tutoring, study skills, dropout prevention Paid and Unpaid work experience Supportive services (Childcare, transportation, etc). Follow-up activities D. VETERAN INFORMATION: Alternative secondary school offerings Occupational skills Training Adult Mentoring Summer Employment Leadership Development Comprehensive guidance and counseling 19. Have you served in the U.S. Military, Naval or Air Service? Yes No less than or equal to 180 days and was discharged under other than dishonorable conditions Yes, eligible veteran Yes, Other Eligible Person Verification Self Attestation DD 214 Military document (ID, other DD form) indicating dependent spouse 20. Are you a campaign veteran? Yes No Are you a disabled veteran? Yes No 21. Are you a recently separated veteran (within last 48 months)? Yes No ----------------------------------------------------------------------------------------------------------------------------------------------------------------- E. EMPLOYMENT INFORMATION: 22. Are you employed? Yes No Comment Verification Self Attestation UI Records/Check Stubs Employer Contact 23. Have you received a termination or layoff notice from last job? Yes No 24. Did you attend a group orientation? Yes No 25. Are you receiving Unemployment Compensation? Yes No Not Applicable Eligible Claimant Referred by WPRS Eligible Claimant Not Referred by WPRS Neither Claimant nor exhaustee Verification UI Records (Benefit History, Wage, Record) UI Records/Check Stubs 26. What is your desired occupation? ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
F. EDUCATIONAL INFORMATION: 27. Current Highest School Grade Completed Do you have a high school diploma? Yes No Other Educational Levels Completed Verification Applicant Statement 28. School Status: In School, High School or Less In School, Alternative School In School, Post High School Not attending school or High School Dropout Not attending school, High School Graduate Verification School Records 29. If you are in high school or less, are you behind a grade level or more? Yes No Not Applicable Verification School Records 30. Are you enrolled in a school program leading to a high school diploma, GED or certificate? Yes No ------------------------------------------------------------------------------------------------------------------------------------------------------------------ G. BARRIERS: 31. Are you a Displaced Homemaker? Yes No Yes LWIA Program Displaced Worker Yes Statewide Program (TANF) Yes Statewide (TANF) and LWIA Programs No Verification Public Assistance Records 32. Do you have limited reading, speaking, writing or understanding of the English language AND is English a second language? Yes No 33. Are you a single parent? Yes No 34. Are you homeless? Yes No Verification Written Statement from Shelter, Social Service agency or Assistance Provider Self Certification 35. Are you a runaway? Yes No Verification Written Statement from Shelter, Social Service agency or Assistance Provider Self Certification 36. Are you an offender? Yes No Verification Court /Police Documents Letter from Probation Officer Self Certification 37. Are you pregnant or parenting youth? Yes No Verification Birth Certificate/Hospital Record of Birth Social Security Card Statement from Social Services Agency Physician s Note 38. Are you in Foster Care? Yes No 39. Are you Basic Skills Deficient? Yes No Verification TABE Score Copy of any generally accepted standardized test School record of reading and/or math skills within the previous 12 months 40. Current TABE Scores: Reading GE 9 Math GE 9 ------------------------------------------------------------------------------------------------------------------------------------------------------------------
H. PUBLIC ASSISTANCE: 41. Are you receiving TANF? Yes No Verification Public Assistance Records/Printout Statement from Social Services Agency 42. Are you receiving Supplemental Security Income? Yes No Verification Public Assistance Records/Printout Statement from Social Services Agency 43. Are you receiving Refugee Cash Assistance? Yes No Verification Public Assistance Records/Printout Statement from Social Services Agency 44. Are you receiving General Assistance? Yes No Verification Public Assistance Records/Printout Statement from Social Services Agency 45. Are you in a household receiving Food Stamps? Yes No Verification Public Assistance Records/Printout Statement from Social Services Agency 46. Are you a publicly supported Foster Child? Yes No Verification Court Documentation Written Statement from State/Local Agency 47. Are you receiving or have you been notified you will be receiving Pell Grant monies? Yes No ------------------------------------------------------------------------------------------------------------------------------------------------------------------ I. SPECIAL YOUTH BARRIERS: 48. Are you a youth facing serious barriers to employment (5% exception)? Yes No 49. Are you a youth requiring additional assistance? Yes No If yes, need assistance in: Completing an Educational Program Securing or Maintaining Employment Reason/Documentation ----------------------------------------------------------------------------------------------------------------------------------------------------------------- J. INCOME INFORMATION: NOTE: If the applicant receives food stamps or TANF, this section does not need to be completed. 50. Due to a disability, will this applicant qualify as a family of one? Yes No 51. What is your family size? Complete Family Size Form (Attached) Verification Public Assistance/Social Service Agency Records Most Recent Tax Return 52. What is your annualized (12 month period) family income? $ Verification Pay Stubs Public Assistance Records Social Security Benefits 53. Does the applicant meet the definition for low income? Yes No (See attached chart) ----------------------------------------------------------------------------------------------------------------------------------------------------------------
K. MISCELLANEOUS: 54. Is LWIA priority for services policy in effect? Yes No 55. Is the applicant not considered Self Sufficient based on LWIA definition? Yes No Not Applicable ------------------------------------------------------------------------------------------------------------------------------------------------------------------ L. STAFF LOCATION: 56. One Stop Location: Southside Virginia Community College Other ------------------------------------------------------------------------------------------------------------------------------------------------------------------ M. ATTACHMENTS NEEDED (In addition to documentation requirements already noted in this application): Document 1. Applicant Certification Statement/Release/Verification 2. Family Size Verification 3. Supportive Services Needs Statement 4. ISS (Individual Service Strategy) 5. Release Form Health Insurance Certification 6. Release Form Photographic Release 7. Release Form Medical Services and Contact Release Form 8. Equal Opportunity Rights Notification Form 9. Follow Up Agreement Please check each form when signature is received. Signature Signature of of Parent Applicant (If Applicable) N. SUMMARY: Date Eligibility Established Income Eligibility Barrier (Indicate) Signature of Applicant Date Signature of Parent Date (If applicant is under 18 years of age at time of application) Signature of Interviewer/Case Manager Date --------------------------------------------------------------------------------------------------------------------------------------------------------------- Date entered into VOS: Entered by Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities. VA RELAY 711
WIA Youth Enhancement Program Initial Assessment Last name: First: Middle: Mailing Address: City: State: Zip Code: 911 Address: Home Phone: ( ) Mobile/ Message#: ( ) Work#: ( ) Age: Date of Birth: / / Male: Female: Maiden name: Education Ethnic Origin: How did you learn about our services? Last Grade completed GED Certificate High School Diploma Some College ( ) Semesters AS/AA Degree in: BA/BS Degree in: MA/MS Degree in: Special Licenses/ Certificates: Caucasian African American American Indian Alaskan Native Asian/Pacific Hispanic Other Newspaper, radio, TV: Employer: School or College: Community Agency: Social Services: Friend, relative, co-worker: Please check if applicable: Valid driver s license: Yes No Transportation available: Yes No Ex-offender: Yes No What is your household size: No. of children under 18: Receiving food stamps: Receiving TANF/VIEW Do you have a child benefiting from TANF? Yes No Were/are you a foster child? Yes No Last employer: Reason for unemployment: Please indicate your interest(s) Tutoring, study skills, dropout prevention Alternative secondary school offerings Summer Employment Opportunities Paid and unpaid work experience Occupational Skill Training Leadership Development Supportive Services Childcare Transportation Other Specify: Mentoring Guidance and Counseling Follow-Up Activities Please check if applicable: Have you been working in farm work in the past 24 months? Do you have any limitations to the type of work you can do? Do you have any mental health or substance abuse issues affecting your life? Do you have any physical/mental disabilities/iep? Is there a reasonable expectation of returning to work? Do you have any prior arrests? Have you failed one or more grade levels? (For high school students) Have you failed one or more SOL test? (For high school students) Are you receiving social Security payments of any kind? (List what type): List any other limitations, barriers, issues, requests or comments: Important! Completing this form does not mean you are registered for WIA Services. This is a service request form only. Notice to Customers: Privacy Protection Act: You are not legally required to complete this form, but refusal to provide the requested information will limit the ability of the WIA Youth Enhancement Program to assist you. Information you furnish to the YEP may be made available to government agencies in order to provide employment and training services to you. It may also maybe used by other human service agencies. Pursuant to the Private Protection Act of 1976, paragraph 2.1-36, Code of Virginia, you are entitled to review, challenge, correct, or explain information about you in the information system. Simply make your request verbally or in writing to a YEP representative. You may be surveyed in the future to determine the effective of the program. Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities. VA RELAY 711
Signature: SS#: Date: South Central Workforce Investment Board 1. Customer agrees to contact the Virginia Workforce Center every Month. 2. Attend classes regularly; submit attendance forms by the 5 th of each month, to the Virginia Workforce Center and make satisfactory progress to the best of his/her ability. 3. Notify the Virginia Workforce Center of changes in: a. Eligibility b. Training Status c. Employment status (including part-time and temporary work) 4. Provide a copy of Pell grant and/or any financial aide award or decision letter 5. Agree to reimburse the Workforce Investment Board the cost of tuition, books, fees and supplies upon receipt of any financial aide from any source. 6. Actively seek employment. 7. Provide specific information regarding employment for exit purposes 8. Respond to all surveys and other request for information including 12-month follow-up after Exit. a. NOTE: In order to measure how well we are meeting our goal we will conduct follow-up activities on all enrollees for a period of 1 year from their exit. In conjunction to UI records used by the State MIS unit, it may be necessary to contact you periodically. 9. Failure to comply with Customer responsibilities may delay or interrupt funding of training and/or services. 10. If any information is misrepresented or falsified, it may be grounds for immediate termination from the program. Part A: I have participated in the formulation of my goals, have received labor market information and reviewed a full list of service offerings, and am in agreement with my WIA TRAINING PLAN. I understand and acknowledge my obligations to the Virginia Workforce Center as listed above. Case Manager Initial Customer Initial Part B: I voluntarily agree to provide information in the follow-up interviews. I understand that this information will be kept strictly confidential. Case Manager Initial Customer Initial I hereby agree to all Customer Responsibilities set forth in the above and have had them explained to me, furthermore I agree to and acknowledge my responsibility in Part A & Part B. Customer Name (print) Customer Signature Date Social Security Number I hereby approve training as specified above as needed to complete the outcome or goal of this Customer. Case Manager Name (print) Case Manager Signature Date Copy to Customer: Customer Initial
South Central Workforce Investment Board SOUTHSIDE VIRGINIA COMMUNITY COLLEGE WIA APPLICANT CERTIFICATION STATEMENT/RELEASE/VERIFICATION (Not to be signed and dated until all documentation has been provided.) I certify that the information on this application is accurate to the best of my knowledge. I understand that my willful misstatement of the facts may cause my forfeiture of rights in the WIA Program and may result in criminal action. I give permission for outside sources to be contacted and for them to disclose any information necessary to verify my eligibility for WIA. I give my Case/Field Manager, all representatives of Southside Virginia Community College, and all WIA personnel my permission to exchange information with any agency or school that may have information that is relevant to my obtaining guidance, counseling, assistance, and services through any WIA Program. I also understand that I may be referred to other agencies for guidance, counseling, assistance, and other services. I authorize my Case/Field Manager to release any information regarding my file that would be helpful to all other agencies to better service my needs. I also understand that my Case/Field Manager will discuss any referrals with me before they are made. I further understand and agree that my social security number and other information on this application will be provided to other government agencies if required by law. I understand and agree to keep all information confidential. Applicant s Signature Date Parent/Guardian Signature Date (If applicant is under 18) Staff Signature Date
South Central Workforce Investment Board SOUTHSIDE VIRGINIA COMMUNITY COLLEGE STATEMENT OF FAMILY SIZE/FAMILY INCOME - INSTRUCTIONS IDENTIFYING INFORMATION Please complete this block with the WIA applicant s name, address, social security number, and application date. FAMILY MEMBERS NAME/RELATIONSHIP TO APPLICANT/FAMILY MEMBER INCOME 1. List the names of all FAMILY MEMBERS living in the applicant s residence on the date of registration. 2. Indicate the relationship of each FAMILY MEMBER to the applicant. 3. Indicate the income during the last six months (26 weeks) of each FAMILY MEMBER living in the applicant s residence on the date of registration. 4. Complete the block Total Number in Family. 5. Complete the block Total Income (if applicable). NAME/LOCATION/REASON 1. List the names of any FAMILY MEMBERS not currently residing in the applicant s residence. NOTE: This should include any FAMILY MEMBER who is not currently living in the residence but would be considered a part of the applicant s family. These absences may be due to temporary and voluntary residence elsewhere (e.g., attending school or college, or visiting relatives). It would not include involuntary temporary residence elsewhere (e.g., incarceration, or placement as a result of a court order). Members of the Armed Forces on extended temporary assignment elsewhere are considered to be assigned involuntarily and would not be considered as part of the applicant s FAMILY. 2. Indicate the location of the absent family member. 3. Indicate the reason for the absence. Include whether the absence is voluntary or involuntary and if it is temporary or permanent. 4. The applicant must sign and date the form. 5. A corroborating witness must sign and date the form attesting to the accuracy of the given information. The corroborating witness may live in or out of the residence and may or may not be related to the applicant. The witness must have verifiable knowledge of the applicant s FAMILY STATUS. DOCUMENTATION In cases where the recommended verification sources of Family Size/Family Income verification are unavailable, or the attainment of such documentation would place an undue hardship on the applicant, then the form at the end of this section may be used. The purpose of the form is to document information that verifies the applicant s family size at time of registration and family income during the last six months (26 weeks). This entails verifying the size and makeup of the applicant s FAMILY. This form is only necessary when eligibility is based on FAMILY INCOME. The applicant should complete the STATEMENT OF FAMILY SIZE/FAMILY INCOME with the assistance of WIA Intake staff to ensure it is completed correctly. The applicant will then take the form to have it signed by a witness who can corroborate the given information. FAMILY 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: (A) A husband, wife and dependent children (B) A parent or guardian and dependent children (C) A husband and wife A dependent child is defined as a child: (A) Under age 19 at the end of the previous calendar year, or (B) Under age 24 at the end of the previous calendar year and was a student. A dependent child was a student if he/she was enrolled as a full-time student at a school during any 5 months of the previous calendar year or took a full-time, on-farm training course during any 5 months of the previous calendar year. The course had to be given by a school or a state, county or local governmental agency. A school includes technical, trade, and mechanical schools. It does not include on-the-job training courses or correspondence schools. Also, regardless of residence and/or citizenship, anyone claimed as a dependent on another person s Federal Income Tax Return for the previous year shall be presumed to be part of the person s family for the current year. To negate this assumption, the person who was claimed as a dependent for income tax purposes would be required to provide information that demonstrates the individual is no longer financially dependent. In applying the definition of family, runaway youth, and court adjudicated youth separated from the family through involuntary temporary residence elsewhere (e.g., institutionalized, incarcerated, or placed as a result of a court order) shall not be classified as dependent children.
An Individual with a Disability must be considered to be an unrelated individual for purposes of income eligibility determination. Only that South Central Workforce Investment Board individual s income, if any, is considered for purposes of eligibility determination. STATEMENT OF FAMILY SIZE/FAMILY INCOME IDENTIFYING INFORMATION Applicant s Name First MI Last Address Social Security Number - - Application Date To be completed by WIA applicant with staff assistance For use in completing this form, the definitions of FAMILY and FAMILY INCOME can be found on the previous page. Please provide information regarding the applicant s FAMILY as requested below. FAMILY MEMBER S NAME RELATIONSHIP TO APPLICANT FAMILY MEMBER INCOME (Annual Based on Last Six Months) Applicant: N/A - Applicant Total Number in Family: (Including Applicant) Total Income: $ If applicable, please complete the following information for FAMILY MEMBERS not currently residing in the applicant s residence (see instructions). NAME LOCATION REASON I attest to the best of my knowledge that the information above is true and correct. Signature of Applicant Date CORROBORATING WITNESS I attest to the best of my knowledge that the information is true and correct. Name Signature Street Address City State Zip Telephone Number Relationship to WIA Applicant
South Central Workforce Investment Board SOUTHSIDE VIRGINIA COMMUNITY COLLEGE MEDICAL HISTORY/RELEASE FORM Full Name: ISY OSY Date of Birth: / / Physicians Name: Social Security # Physician s Number: Medicaid Number Health Insurance Provider: Policy Number: List All: Health Conditions: Medications: List All Allergies (Food/Drug/Other): List any other major diseases, surgeries, conditions, or illnesses not covered above: Emergency Contact Info: Name: Contact Number: Relationship: I give permission for to receive medical and emergency care at the appropriate medical facility while being a participant in the Southside Virginia Community College WIA Programs, and for a physician and other medical personnel to treat the participant in an appropriate manner in case of an emergency. I also give permission for the medical/nursing staff to refer the participant to a private physician and for transportation, treatment, immunization, x-rays, or operative procedures that may be deemed necessary to protect the health of the participant. Applicant s Signature: Parent/Legal Guardian Signature: (Required if under 18) Date: Date:
Daytime Phone Number Cell Number South Central Workforce Investment Board SOUTHSIDE VIRGINIA COMMUNITY COLLEGE PHOTOGRAPHIC RELEASE FORM Name Social Security Number - - Check One: ISY OSY Summer Employment Yes. I hereby consent that all photographs, videotapes, films, or other electronic and technology-produced images of me and/or my personal belongings and/or recordings made of my voice, or success stories, may be used by Southside Virginia Community College, the WIA Program officials, and/or others for the purposes of illustration, advertising, publication and promotion, without monetary remuneration for said likenesses. No. I do not give consent for the above. Applicant s Signature Date Parent/Guardian Signature Date (If applicant is under 18) Staff Signature Date
South Central Workforce Investment Board Follow-Up Agreement Enrollee Name SS# Virginia Workforce Center You are being enrolled in a Youth Program federally funded under WIA. The program is administered by the above Workforce Investment Board. It is our goal to help you obtain the education training or job search assistance that will help you strengthen your future. In order to measure how well we are meeting our goal we will conduct follow-up activities on all enrollees for a period of 1 year after their exit. Please list three people, not residing in your household, who will always know how you may be contacted. Name: Address: Relationship: Phone: Name: Address: Relationship: Phone: Name: Address: Relationship: Phone: I voluntarily agree to provide information The follow-up agreement has been in the follow-up interview. I understand explained and a copy is given to the that the information will be kept strictly enrollee. confidential. Enrollee Date WIA Youth Case Manager Date
South Central Workforce Investment Board SOUTHSIDE VIRGINIA COMMUNITY COLLEGE HEALTH INSURANCE CERTIFICATION Name Social Security Number - - Check One: ISY OSY Summer Employment Check the appropriate statement: I do have medical insurance Policy Name Policy Number I do not have medical insurance. I certify that the information on this certification is correct to the best of my knowledge. I understand that if I do have medical coverage, it must be billed before any appropriate WIA reimbursement is paid. Applicant s Signature Date Parent/Guardian Signature Date (If applicant is under 18) -------------------------------------------------------------------------------------------------------------------------------------------- Witnessed: Yes No Staff Signature Date
South Central Workforce Investment Board SOUTHSIDE VIRGINIA COMMUNITY COLLEGE INDIVIDUAL SERVICE STRATEGY (ISS) Name Social Security Number - - ISS/Intake Date Check One: ISY OSY Summer Employment COMPREHENSIVE NEEDS ASSESSMENT: Strengths (Ask youth what things he/she is good at and what things he/she enjoys doing): Youth lacks or has inadequate supply of the following: Education Childcare Transportation Work Attire Work Tools Work Readiness Training Life Skills Training Self Concept/Esteem Income School Supplies Other (Specify) CHECKLIST FOR SUCCESS (Needed Services): Work Experience Childcare Transportation Supportive Services Work Readiness Training Educational Enhancement Life Skills Training Leadership Development Other (Specify) TO DO LIST (Goals/Action Steps) Type of Goal Work Readiness Action Steps: 1. 2. 3.
OBJECTIVE ASSESSMENT: Measurements (*If applicable) 1. Formal interview Date Administered Score/Report Summary 2. *Math Testing 3. *Reading Testing 4. *Career Readiness Certificate 5. Wizard Career and Work Plan 6. Career Scope 7. Pre-Assessment 8. Post-Assessment *If Needed Comments/Summary: Modifications (If Needed Indicate Date): 1. 2. 3. Additional Comments: Applicant s Signature Date Parent/Guardian Signature Date (If applicant is under 18) Staff Signature Date Page 2 Individual Service Strategy (ISS)
South Central Workforce Investment Board SOUTHSIDE VIRGINIA COMMUNITY COLLEGE WIA SUPPORTIVE SERVICES NEEDS STATEMENT Name Social Security Number - - Check One: ISY OSY Summer Employment Supportive Services Requested (Check all that applies): Transportation (Explain : ) Child Care (Explain : ) Work Related Attire/Tools (Explain : ) Other (Please specify : ) Can customer receive these services through other programs? Yes No If yes, indicate what service(s) and by whom: Why is this service needed? How will this service be documented (Check all that apply): Attendance Record Receipts Childcare Contract/Attendance Record Invoices Other (Please specify) No Supportive Service Needed Applicant s Signature Date Parent/Guardian Signature Date (If applicant is under 18) -------------------------------------------------------------------------------------------------------------------------------------------- Approved for Submission: Yes No Staff Signature Date Approved for Payment: Yes No Director of Youth Programs Signature Date