ServiceCorps 2014 The Coatesville Youth Initiative s Summer Service & Leadership Development Program Youth Application Due by Friday, March 21, 2014-4pm www.coatesvilleyouthinitiative.org 2014 Coatesville Youth Initiative. 50 S. First Avenue, Coatesville, PA 19320
Application Information The Coatesville Youth Initiative s ServiceCorps (ServiceCorps) is a program for Coatesville Area School District youth between the ages of 14-18, which combines an eight-week employment experience with a challenging life and leadership skills development curriculum. This is a life-changing opportunity for young people to engage in personal and professional development activities and service project(s), so they become inspired and poised to carry our community toward a positive future. ServiceCorps offers work experience, opportunities to serve the community, life and leadership skills and a summer income. The program is free of charge, and we provide transportation from the Brandywine Center (744 East Lincoln Highway. Coatesville, PA 19320) to the work sites, and back. ServiceCorps is open to youth residing in the Coatesville Area School District between the ages of 14 through 18, as of June 23, 2014. ServiceCorps application and all required documents are due by Friday, March 21, 2014 at 4pm. We highly encourage all those interested in participating in ServiceCorps to attend, with a parent or guardian, one of the ServiceCorps Parent / Guardian Information Sessions listed below: o Tuesday, March 4, 2014, 6:30pm The Brandywine Center, 744 East Lincoln Hwy (4 th floor conference room), Coatesville, PA 19320 OR o Thursday, March 6, 2014, 6:30pm Caln Township Building, 253 Municipal Drive, Thorndale, PA 19372 The following are the components of this application. You may use this as a checklist. Applicant Information Parent / Guardian Information Emergency Contact Information Applicant Questionnaire Applicant Questionnaire pt. 2 (FOR RETURNING STUDENTS ONLY) Certification of Accuracy Reference Forms (2) Copies of Required Documents (Required Documents Checklist available on the last page) Submitting the Application - Each applicant may only submit one application. The application may be submitted through various ways: o Email: Email the completed application (including references and required documents) as a pdf file to mena@coatesvilleyouthinitiative.org with the subject line: ServiceCorps 2014 Applicant. o Fax: Fax the completed application to (including references and required documents) 610.380.9081. o Mail: Mail the completed application (including references and required documents) to Coatesville Youth Initiative 50 S. 1 st Avenue, Coatesville, PA 19320. Attn: ServiceCorps Application o Drop off: Drop off the completed application (including references and required documents) at our office 50 S. 1 st Avenue, Coatesville, PA 19320. The program is limited to 40 youth. Submission of an application does not guarantee acceptance in the program. Participants are chosen based on the quality of their application, references, availability, and interview process. The ServiceCorps program begins with a two-day orientation on June 20-22, 2014 for participants. Selected participants must attend the orientation to successfully be enrolled in the ServiceCorps program. For more information or if you have questions about completing the application or the required documents, please contact Mena Badros at mena@coatesvilleyouthinitiative.org or call him at 610-380-0200 x204.
Application (page 1/7) APPLICANT INFORMATION: Applicant name First Last Social security number - - Male Female Birth date month / day / year Age Citizenship status US Citizen Permanent Resident Alien Other (Check one) Mailing address Street Address City State Zip Home phone ( ) - Cell phone ( ) - Township Email Please print clearly email is our primary means of contact for this program Were you in the program last year? Yes No (If yes, please make sure to complete the additional questions on pg. 5) What is your t-shirt size? XS S M L XL XXL XXXL Grade and school you are currently attending: Ethnicity (Check one) American Indian Asian (non-hispanic) Black (non-hispanic) Pacific Islander White (non-hispanic) Hispanic/Latino Other Do any of the following apply to you? Disabled Foster Care Homeless Teen-Parent (Check all that apply) Runaway Offender/Court Involved How did you hear about the ServiceCorps program? In order to provide the best possible program for our students, we ask if you are currently or have previously been treated for any mental, emotional or behavioral problem?* Yes No (*The answer to this question does not disqualify you from the selection process) Were you ever suspended or expelled during this school year? Yes No (If yes, please explain below)
Application (page 2/7) Please list all dates (and reasons) that you anticipate being away from the ServiceCorps program if you were to be selected (vacations, weddings, sports camps, etc). [The program runs starts with an orientation Friday, June 20 th until Sunday, June 22 nd then Monday, June 23 rd is the first day at the work sites. The last day in the program is Friday, August 15 th. Graduation is scheduled for Monday, August 18 th. To graduate from this program, participants are required to complete at least 238 hours over the duration of the program, and attend mandatory events: Program Orientation June 20th 22nd and the Service Project August 16 th, in addition to other requirements] PARENT / GUARDIAN INFORMATION: Name Email First Last Please print clearly email is our primary means of contact for this program Mailing Address Daytime phone ( ) - Cell phone ( ) - Relationship HOUSEHOLD INFORMATION: Is the applicant s household currently receiving public assistance? Yes No If yes, type of public assistance Safety Net/Home Relief Food Stamps SSI (Check all that apply) Temporary Assistance for Needy Families (TANF) Other Total annual household $0 to $24,999 $25,000 to $49,999 $50,000 to $74,999 (Check one) $75,000 to $99,999 $100,000 or more Number of family members currently living in household VOLUNTEERING: Would the parent/guardian be interested in volunteering with the ServiceCorps program this year? Yes No Ways to volunteer as parent/guardian: (Check all that apply) Providing snacks/water/juice for 40 participants once Helping with the community service project Chaperoning scheduled trips EMERGENCY CONTACT INFORMATION: Emergency contact name #1 & number / ( ) - Emergency contact name #2 & number / ( ) - Emergency contact name #3 & number / ( ) -
Application (page 3/7) CERTIFICATION OF ACCURACY I, the undersigned, certify that all information on this form is true and correct. I understand that my statements are subject to verification. I further understand that any false statements may subject me to criminal prosecution under both Pennsylvania and Federal laws, and to civil action for return of all monies received. I agree and accept that I will abide by all applicable rules and regulations of this program. If selected for the ServiceCorps program, I will participate to the best of my abilities, obey all rules and guidelines of the program, and be the best representative of ServiceCorps that I possibly can. Applicant s signature: Date: Print name: As the parent/guardian of the student applicant, I approve of my child s application to the Coatesville Youth Initiative s ServiceCorps program and have read this application and the program information. Parent/Guardian signature: Date: Print name:
Application (page 4/7) APPLICANT QUESTIONNAIRE: Please answer all of the following questions (feel free to continue on a separate sheet of paper) What do you know about the ServiceCorps program? Our program goals are Youth Development, Meaningful Service, Civic Engagement and Work-Readiness. Please describe how you will personally benefit from the goals of the ServiceCorps program. (Discuss at least 2 of the 4 items) What three personal characteristics will you bring to the ServiceCorps program, and what do you hope to learn / take away from the program? How will your presence benefit the program overall? And how will your peers benefit from you?
APPLICANT QUESTIONNAIRE PT.2: Summer Youth ServiceCorps Program 2014 Application (page 5/7) If you were in the program last year, please answer the following questions: Explain what contributions you made to ensure the success of last year s recycling project. Be specific. Identify where you slacked off in the ServiceCorps program last year and how you will ensure it will not happen again. Why should you be selected to come back to the ServiceCorps program this summer?
This page is intentionally left blank. Please continue to next page to complete application.
FIRST REFERENCE FORM: Summer Youth ServiceCorps Program 2014 Application (page 6/7) Provide an adult reference who has worked with you at school, in sports, church, clubs or community organizations (not family members). These references are a required part of our selection process. This form should be returned along with the application; emailed to mena@coatesvilleyouthinitiative.org, faxed to 610.380.9081, or sent to Coatesville Youth Initiative, 50 S. 1 st Avenue, Coatesville, PA 19320. It is due by Friday, March 21 st at 4pm. Any questions, please call 610-380-0200 x 204. Name of reference Date Name of applicant Reference Email for follow-up questions Phone number ( ) - How do you know the applicant? Since when do you know the applicant? In as much detail as possible, please describe the applicant s involvement in his/her community and school, and his/her experiences, abilities and leadership potential. This program requires a positive attitude, respect for others and listening skills. Please critique the applicant s attitude, respect for others and listening skills, based on your experience with him/her. Please critique the work ethic of the student applicant. The Summer Youth ServiceCorps program is full-time service four days a week and a full day of skills training one day a week. Why do you think this student should be considered for the ServiceCorps program? Additional information you wish to tell us about the student applicant:
This page is intentionally left blank. Please continue to next page to complete application.
Application (page 7/7) SECOND REFERENCE FORM: Provide an adult reference who has worked with you at school, in sports, church, clubs or community organizations (not family members). These references are a required part of our selection process. This form should be returned along with the application; emailed to mena@coatesvilleyouthinitiative.org, faxed to 610.380.9081, or sent to Coatesville Youth Initiative, 50 S. 1 st Avenue, Coatesville, PA 19320. It is due by Friday, March 21 st at 4pm. Any questions, please call 610-380-0200 x 204. Name of reference Date Name of applicant Reference Email for follow-up questions Phone number ( ) - How do you know the applicant? Since when do you know the applicant? In as much detail as possible, please describe the applicant s involvement in his/her community and school, and his/her experiences, abilities and leadership potential. This program requires a positive attitude, respect for others and listening skills. Please critique the applicant s attitude, respect for others and listening skills, based on your experience with him/her. Please critique the work ethic of the student applicant. The Summer Youth ServiceCorps program is full-time service four days a week and a full day of skills training one day a week. Why do you think this student should be considered for the ServiceCorps program? Additional information you wish to tell us about the student applicant:
This page is intentionally left blank. Please continue to next page to complete application.
Required Documents Checklist In order to be placed at a service site, you will need to provide certain documents to us. In addition to the application and references, you must submit COPIES of one (1) item from each of the 5 categories listed below as it applies to you. These items are needed to officially complete your enrollment so that you are eligible for a ServiceCorps position. These copies are also due by Friday, March 21 st at 4pm. NO COPIES WILL BE MADE AT THE COATESVILLE YOUTH INITIATIVE OFFICE. 1. Proof of Age Birth Certificate OR PA Driver/Non-Driver s License OR Alien Registration Card OR Valid U.S. Passport 2. Proof of Social Security Number Social Security Card (ONLY) 3. Proof of Address Home Utility Bill OR Official Mail from School, or a Federal, State or City Agency Please provide ONLY if applicable 4. Proof of Disability: Official documentation As applicable certifying disability from a physician, ACS, HRA, School, Social Service agency or authorized entity. 5. If previously or currently court involved, please provide official documentation to explain: Your involvement Sanctions from the court officials Please note: all documents submitted must be valid as of the submission date.