Summer YouthWorks Employment Program 2012 YOU MUST VISIT: www.massyouthemployment.org and create a Youth account by clicking on Apply for a Youth Job prior to submitting a SYEP application APPLICANTS MUST BE: From Haverhill, Lawrence, Methuen Between 14-21 years old Eligible to work in the U.S. Income Eligible PLEASE RETURN COMPLETED APPLICATIONS TO LAWRENCE VALLEYWORKS: Mondays Fridays 2:00 pm 4:00 pm HAVERHILL VALLEYWORKS: Tuesdays & Thursdays 2:00 pm 4:00 pm VWCC YOUTH DEPARTMENT STAFF WILL BE AT THE FOLLOWING HIGH SCHOOLS LAWRENCE HIGH SCHOOL: Mondays & Wednesdays 10:00 am 1:00 pm LHS LEARNING CENTER: Fridays 10:00 am 1:00 pm HAVERHILL HIGH SCHOOL: Tuesdays & Thursdays 9:30 am 1:00 pm APPLICATIONS MUST BE RECEIVED BY NO LATER THAN MONDAY, APRIL 30, 2012 APPLICATIONS RECEIVED AFTER MONDAY, APRIL 30, 2012 WILL NOT BE ACCEPTED Applications will be reviewed by the ValleyWorks Career Center ACCEPTANCE OF COMPLETED APPLICATION DOES NOT GUARANTEE EMPLOYMENT SUMMER JOBS WILL BE DETERMINED BY A LOTTERY LOTTERY: TUESDAY MAY 15, 2012 LAWRENCE: 439 SOUTH UNION STREET SUITE 106 HERITAGE PLACE BUILDING 2 LAWRENCE, MA 01843
LAWRENCE: 439 SOUTH UNION STREET SUITE 106 HERITAGE PLACE BUILDING 2 LAWRENCE, MA 01843 YOUTH NAME Summer YouthWorks Employment Program Required Eligibility Documentation Checklist HERE IS WHAT EVERY YOUTH NEEDS: Youth must meet eligibility criteria to participate in the 2012 Summer YouthWorks Employment Program. Part of the eligibility criteria for this program is that each youth meets residency requirement and be economically eligible. REQUIRED DOCUMENTATION All youth are required to provide proof of their age, citizenship/authorization to work, social security number, selective service (if applicable), and address Youth must answer Yes to the following 2 questions to qualify for the 2012 Summer YouthWorks Employment Program: Is the youth between the ages of 14-21? Yes No Does the youth live in Haverhill, Lawrence, or Methuen, MA? Yes No Proof of Age/Citizenship: (only need one from the list below) U.S. Birth Certificate U.S. Passport Unexpired Resident Alien Card (both sides must be copied) Picture ID: (only need one from the list below) NOTE: FOR YOUTH UNDER 18 YEARS OF AGE, YOU MAY USE A REPORT CARD IF YOU DO NOT HAVE AN ID School ID Massachusetts ID Proof of Selective Service (Only for males 18 years or older): (only need one from the list below) Selective service online verification Selective service registration record IF APPLICABLE Documentation of YOUTH RISK BARRIER: Please check all of the following barriers that apply 1. Court Involved (Juvenile arrest, gang-involved, probation, CHINS, DYS-committed) Yes No If yes, Case Worker Name Must have letter from DYS or Probation 2. State Custody (Foster Care/DCF) Yes No Must have letter from DCF 3. Homeless Yes No Letter from individual providing temporary residence Letter from Shelter/Social Service Agency Applicant statement Proof of Social Sec. No. (only need one from the list below) Social Security Card Letter from State Agency Verifying Number Proof of Family Size: (only need one from the list below) Birth Certificates for all family members Health cards for all family members Lease agreement with family members listed Proof of Address: (only need one from the list below) Utility bill Lease agreement Proof of Income Eligibility: See below for necessary documents Proof of Free or Reduced Lunch Public Assistance Records/Printout Food Stamp Card with Current d Receipt Alimony Agreement Award letter from Veterans Administration Bank Statements (Direct Deposits) Compensation Award Letter Court Award Letter Employer Statement/Contact Business Financial Records Housing Authority Verification Pay Stubs Pension Statement Quarterly Estimated Tax for the Self-Employed Social Security Benefits Unemployment Insurance Documents Written statement from other Federal, State, or Local agency Applicant Statement if no other forms of documentation are available must be supported with corroborative contact or reliable witness Telephone verification if no other forms of documentation are available Document Inspection verification if provided document cannot be legally photocopied
LAWRENCE: 439 SOUTH UNION STREET SUITE 106 HERITAGE PLACE BUILDING 2 LAWRENCE, MA 01843 Summer YouthWorks Employment Program Application To be completed by youth: (Please complete all sections of the application) Social Security Number: First Name: Middle Initial: Street Address: State: : / / Last Name: Apt. #, City: Zip: Phone Number: ( ) - Cell Phone Number: ( ) - of Birth: / / Age: Gender: Male Female Email: Parent Name: Parent Work Phone Number: ( ) - Emergency Contact Name: Emergency Contact Phone: ( ) - Personal Goals: Are you or any member of your family receiving any of the following? TAFDC EAEDC SSI/SSDI Refugee Assistance Food Stamps Child Support Unemployment Insurance Benefits Workman s Compensation None Ethnicity: Caucasian/White African American Hispanic/Latino Asian Native American Hawaiian/Pacific Islander Other: Family Size: Estimate your family income for the last 6 months: Are you eligible for Free Lunch? Yes No Are you eligible for Reduced Lunch? Yes No Are you a Court-Involved youth (juvenile arrest, gang-involved, probation, CHINS, DYS Committed? Yes No Are you a State-Involved Youth (Foster Care/DCF)? Yes No Are you homeless? Yes No Do you have an IEP or a disability? Yes No Are you a teen parent? Yes No Are you the child of a single, working parent? Yes No Are you a high school dropout or have poor academic performance? Yes No Are you a foreign immigrant or lack English language fluency? Yes No NO RISK FACTOR Work History: Employer Name: Address: City: State: Zip Code: Job Title: Phone: ( ) - Start : / / End : / / Wage: Hours per week: Reason for Leaving:... Employer Name: Address: City: State: Zip Code: Job Title: Phone: ( ) - Start : / / End : / / Wage: Hours per week: Reason for Leaving:
Summer YouthWorks Employment Program Application Education: Are you currently attending school? Yes No If no, highest grade completed? School ID#: Current Grade: Graduation Year: Middle School High School College or Trade Name of School Course of Study s Attended Diploma/ Degree (or current grade in school) MCAS Scores: Test : Math Score ELA Score Science Score Test : Math Score ELA Score Science Score Please check the following if you agree to allow Valleyworks Career Center to use the following. Valleyworks Career Center Student Specialist may verify information regarding student s MCAS results. This Information is used to determine which other resources may support the student in their academic activities, work experience, remediation, tutorial services, work readiness training, job search and/or other services. Valleyworks Career Center may use photographic images of this youth in a work or study environment in promotional materials. Would you like to be enrolled in Connecting Activities/Work Ready Program Yes No Work Interest: Job preferences [check all that apply]: I prefer to work outdoors or indoors I prefer to work in a group or by myself I prefer to work with people or with things I prefer to work in a quiet setting or in public environments I prefer physical work or using problem solving skills Job skills or experience: Computer/data entry Customer services/reception Childcare/youth leader Counseling Housekeeping Landscaping/yard work Maintenance/janitorial Office/filing Construction/painting Teacher s aide Other: Do you have a valid driver s license? Yes No Do you have reliable transportation? Yes No Explanation of Participant Agreement: Valleyworks Career Center (VWCC) is funded in large part by federal and state grants. This data helps determine the level of funding for our region in future years. Participant agreement: I allow ValleyWorks Career Center to collect information on my eventual employment. I agree to provide ValleyWorks Career Center with information including the starting date, position title, name and address of employer, starting wage and benefits when I next become employed. I agree to this as a condition for using VWCC resources, whether or not employment is a direct result of using VWCC services, resources or referrals, as VWCC is required to report this information on all registered customers, and this directly impacts future funding for employment and workforce development programs and resources in this region. I also agree to allow VWCC to release employment information to prospective employers. I hereby certify and attest, under penalty of perjury, that the information stated above is true and accurate, and understand that the above information, if misrepresented or incomplete, may be grounds for termination from certain services. I acknowledge that the accuracy of the information for eligibility is subject to external verification and may be released for such purposes. I approve the release of the contents of my application and file to service providers for the purpose of evaluating my qualifications for their program. My signature also attests that I have received information regarding my rights to equal opportunity/nondiscrimination and how to file a grievance, including a copy of the notice Equal Opportunity and the Law and How to File a Formal Complaint/Grievance, and that I understand my social security number is being documented for standardized program information reporting purposes; and I have been supplied with a description of the full array of VWCC Services. Applicant Signature Parent/Guardian Signature - Required if less than 18 Years of Age ValleyWorks Career Center Staff Signature ** ALL INFORMATION OBTAINED ON THIS REGISTRATION WILL BE KEPT CONFIDENTIAL** Required Documentation In addition to this application, copies of the following must be attached to this application: U.S. Birth Certificate or current Resident Alien Card Selective Service Verification, if applicable Proof of address Photo ID [school or Mass. ID] Proof of income Social Security Card Proof of Youth Risk Factor, if applicable
Summer YouthWorks Employment Program Application FREE OR REDUCED LUNCH FORM Part of the eligibility criteria for this program is that each youth meets residency requirement and be economically eligible. This form is being utilized to document income eligibility. Completion of this form does not guarantee employment placement as employment placement will be awarded on a lottery basis. The deadline for receipt of completed applications is Monday April 30, 2012. Applicants submitting a completed application prior to the deadline will participate in the lottery. Lottery drawing will take place on Tuesday May 15, 2012. Youth or parent must have their school complete and sign this portion of the form. Youth name: Name of School: Current Grade in School: To be completed by school personnel: This youth is currently has been approved and is eligible as defined by National School Lunch Act for: Free Lunch Reduced Lunch School stamp or seal: I ATTEST THAT THE INFORMATION STATED ABOVE IS TRUE AND ACCURATE AND UNDERSTAND THAT THE ABOVE INFORMATION, IF MISREPRESENTED, OR INCOMPLETE, MAY BE GROUNDS FOR IMMEDIATE TERMINATION AND/OR PENALTIES AS SPECIFIED BY LAW. School Staff Signature: : / / Print School Staff Name: Job Title: Phone #: