North Shore Youth Career Center Summer Application Instructions

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1 orth Shore Youth Career Center Summer Application Instructions Application All submitted summer application forms must be completed in full. They must include all required back up documentation. (All applicants under 18 must have their legal guardian/parent sign designated areas) Required Back Up Documentation * Proof of Address Proof of Age Proof of Citizenship (must be able to work legally in the United States) Proof of Household Income Proof of Social Security Card/umber All required back up documentation must be submitted with application in order to be considered for summer jobs Deadline All completed applications and back up documentation must be submitted to the orth Shore Youth Career Center, 181 Union Street, Lynn, MA 01902, no later than May 31, All applications submitted after this date will be waitlisted Workshops All youth participating in summer jobs must complete the workshop series to be eligible. Questions or concerns regarding the application process please call the orth Shore Youth Career Center at and ask to speak to a youth representative. *a listing of approved back up documentation is included in the summer application packet Page 1 of 6

2 List of documents Proof of Address Current Utility bill with address on it Copy of Lease Stamped envelope within the past 30 days Current SAP or TAFDC benefits letter Proof of Age Copy of birth certificate Copy of passport Copy of unexpired I-94 card (green card) Proof of Citizenship US birth certificate US naturalization certificate Unexpired I-94 card (green card) US Passport stating that you are a US Citizen Proof of Household Income Copy of most recent paystubs for all members of the family with year to date totals Copy of SSI;SSDI;Survivor Benefits from the Social Security office Copy of most resent proof of SAP;TAFDC benefits Proof of Social Security umber Copy of social security card Copy of letter from Social Security office with social security name and number included Please note that not all supporting backup documentation is listed on this sheet. These are the most commonly used. If you have a unique circumstance regarding your back up documentation please call a orth Shore Youth Career Center representative for additional options. Page 2 of 6

3 Date you completed the form: F1rst Jobs Summer Application Form 2013 First ame: Last ame: Street Address: City: State: Zip Code: Home Phone: Other Phone: Address: Date of Birth: Male: Female: Last Grade Completed : Currently In School: Y School/Program : Graduate: Y Graduation Year: Take MCAS: Y Pass Reading: Y Pass Math: Y Pass Biology: Y Currently In GED Program: Y Do/Did you Receive Free Lunch: Y Are you on an IEP/504: Y Do you have a disability: Y Social Security: Optional White Hispanic/Latino African/American Asian American Indian Other Are you Bilingual: Y Check all that apply: Homeless Foster Youth/Former Foster Child of single working guardian Limited English Skills Teen Parent DYS/Offender Disability Are you working now: Y Where: Office Use Only Employment Placement Start Date / / End Date / / Hourly Wage Job Sector Choose one: on-profit Private Public Payroll Provider Program Leverage Information (check all that apply) WIA Title I Youth WIA Title I Adult WIA ARRA Connecting Activities Mass. WBLP Used DYS Bridging the Opportunity Gap DOE Grant 597 Pathways for MCAS Success Pathways to Success by 21 DYS BOG Grants Funding Source Youthworks Eligible First Jobs Eligible Page 3 of 6

4 FAMILY MEMBERS (Include all family members who presently reside with you and are related by blood, marriage and decree of court and can be included in one or more of the following categories.) A. Husband, Wife and Dependent Children. B. A Parent or Guardian and Dependent Children. C. Husband and Wife. AME AGE RELATIOSHIP ICOME LAST 6 MOTHS APPLICAT CERTIFICATIO: I attest that the information on the application is true to the best of my knowledge and that there is no intent to commit fraud. The information on the application will be used to determine eligibility and the information is subject to external verification and may be released for such purposes. I am also aware that I am subject to immediate termination if I am found ineligible after enrollment, and may also be subject to criminal prosecution, if falsified documentation was provided. APPLICAT'S SIGATURE DATE PARET/GUARDIA SIGATURE ( If applicant is under 18) I authorize SIGATURE OF ITERVIEWER DATE ame of School your child is attending to release math and reading scores. FOR OFFICE USE OLY Family Verified Economically Disadvantaged: Yes o IF YES: Gross Wages $ 1.Family Income 2.Cash TAFDC, Food Stamps Other Includable Income $ 3.Family of One: A. Disabled 6 Month Total $ B. Runaway C. Free Lunch Annualized $ D. Chapter 1 Program E. Foster Child Family Size Total Allowed $ If O: 1. Eligible as Exception: Reason: 2. Over Income - ot an Exception Reason: Page 4 of 6

5 Authorization to Release Personal Information I,, the undersigned parent or legal guardian of, a minor child, hereby authorize the orth Shore Career Center to obtain information from my minor child s school regarding: Free/Reduced Lunch Status IEP/504 Plan Report Card/MCAS Scores Drop Out Verification This verification is valid from: and will expire on This form is being used for the sole purpose of eligibility for employment. Additionally, I the undersigned person, hereby authorize the orth Shore Career Center to release a photograph of my minor child in conjunction with the release of information. I reserve the right to review and approve any information to be published about my minor child by the orth Shore Career Center before the actual publishing of such information. Further, I understand and acknowledge that I, or my minor child, will not receive any fee for providing this information and photograph; and that any services that my minor child may be eligible for will not be affected in any way by this release. Signature: (parent or legal guardian if under 18) Print name: Print Address: Print Date: Witness: Printed ame & signature Date Witness: Printed ame & signature Date Page 5 of 6

6 Autorización Para Liberar Informacion Personal Yo,, la firma del padre o guardián legal de, el niño menor, le autoriza al orth Shore Career Center que Obtenga la información del niño menor con referencia a la escuela: Gratis/Lonche reducido IEP/504 Plan ota/mcas Puntuages Verificacion que dejo la escuela Esta verificación es valida desde y va a expirar en Esta forma esta siendo usada para el solo propósito de elegibilidad de empleo. Adicionalmente, yo la persona que firma, le autorizo al orth Shore Career Center que puede mostrar fotos de mi hijo/a menor junto con otras informaciones del programa. Yo reservo el derecho de repasar y aprobar cualquier información que sea publicada de mi niño menor por el orth Shore Career Center antes de la actual publicación de la información. Entiendo y comprendo que ni yo ni mi niño menor vamos a recibir dinero por proveer esta información y fotografías; y que ningún servicio que mi hijo/a menor pueda ser elegible le va a afectar en ningún modo por estas publicaciones. Firma: (padre o guardián legal si es menor de 18) ombre en Molde: Direccion en Molde: Fecha en Molde: Testigo: ombre molde & Firma Fecha Testigo: ombre molde & Firma Fecha Page 6 of 6

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