Summer Employment Application 2014

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Summer Employment Application 2014"

Transcription

1 Summer Employment Application 2014 Thank you for your interest in the North Shore Youth Career Center s Summer Youth Program The next step in the process is to complete this application and include the required documentation to determine your eligibility. When you have completed this application, please call to set up an appointment with a Youth Career Center Staff member listed below. All applications must be completed in full, must include all required backup documentation, (All applicants under 18 must have their legal parent/guardian sign designated areas) and be submitted to the North Shore Youth Career Center, 181 Union Street, Lynn, MA 01902, no later than Friday, May 30, All youth who submit applications after this date will be waitlisted. Career Readiness Workshops All youth are required to complete the workshop series to obtain job placement. Questions/concerns/appointments regarding the application/process please call the North Shore Youth Career Center staff. Soren Balea Bob Fraizer Ann-Marie O Keefe Junardy Jean-Charles *a listing of approved backup documentation is included in the Youth Works application packet beginning on page 2. Revised as of 04/23/2014 Page 1 of 6

2 List of backup documentation required for those summer youth who reside in Lynn, Peabody and Salem. For youth who live outside these three cities please contact Youth Career Center Staff listed on (page 1). These are the most commonly used. Please select one of the documents from each of the four sections. 1. Proof of Address Current Utility bill with address and dated within the past 30 days; can be in parents name Current Lease Postmarked envelope within the past 30 days Current SNAP or TAFDC benefits letter; must include youth name; dated within the last six months 2. Proof of Age/US Citizenship US birth certificate or US passport Valid permanent resident card/i-94 card (copy the front and back) US naturalization certificate 3. Proof of Household Income Free or Reduced Lunch Student s Individual Education Plan (IEP) Most recent paystubs for all members of the family with year to date totals SSI;SSDI;Survivor Benefits from the Social Security office Current SNAP or TAFDC benefits letter; must include youth name; dated within the last six months 4. Proof of Social Security Number Social security card Letter from Social Security office with social security name and number included Please note that not all sample backup documentation is listed on this sheet. If you have a unique circumstance regarding your backup documentation please call a North Shore Youth Career Center representative for additional options. Revised as of 04/23/2014 Page 2 of 6

3 Date you completed the form: For Internal Use Only Access Moses Moses ID#: CA Summer Employment Application 2014 First Name: Last Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Date of Birth: Male: Female: Social Security.. Currently in School: Y N School Name: Graduate: Y N Do/Did you Receive Free Lunch: Y N Graduation Year: Optional White Hispanic or Latino Black or AfricanAmerican Asian American Indian Other Are you Bilingual: Y N Language: Are you working now: Y N Where: Check all that apply: Homelessness Foster Youth/Former Foster Child of single parent/guardian Limited English Skills/Immigrant Teen Parent Court Involved/DYS IEP/504 Disability/Special Needs Poor Academic Performance/School Dropout For Internal Use Only YW Eligible F1rstJobs Date Job Filled: Revised as of 04/23/2014 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. NAME AGE RELATIONSHIP Self APPLICANT CERTIFICATION: 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. APPLICANT'S SIGNATURE DATE PARENT/GUARDIAN SIGNATURE ( If applicant is under 18) SIGNATURE OF INTERVIEWER DATE Revised as of 04/23/2014 Page 4 of 6

5 Authorization to Release Personal Information I,,the undersigned parent or legal guardian of, a minor child, hereby authorize the North Shore Youth Career Center to obtain information from my minor child s school regarding: Free/Reduced Lunch Status IEP/504 Plan This verification is valid from: and will expire on 8/31/2014 This form is being used for the sole purpose of eligibility for employment. Additionally, I the undersigned person, hereby authorize the North Shore Youth 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 North 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: Youth Staff: Printed Name & signature Date Revised as of 04/23/2014 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 North Shore Youth Career Center que Obtenga la información del niño menor con referencia a la escuela: Gratis/Lonche reducido IEP/504 Plan Esta verificación es valida desde y va a expirar en 8/31/2014_ Esta forma esta siendo usada para el solo propósito de elegibilidad de empleo. Adicionalmente, yo la persona que firma, le autorizo al North Shore Youth 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 North 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) Nombre en Molde: Direccion en Molde: Fecha en Molde: Trabajador de Juventud: Nombre molde & Firma Fecha Revised as of 04/23/2014 Page 6 of 6

Summer Employment Application 2015

Summer Employment Application 2015 Summer Employment Application 2015 Thank you for your interest in the orth Shore Youth Career Center s Summer Youth Program 2015. If you are a youth age 14 to 21, the next step in the process is to complete

More information

North Shore Youth Career Center Summer Application Instructions

North Shore Youth Career Center Summer Application Instructions 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

More information

Benedictine College Financial Aid

Benedictine College Financial Aid 2015 2016 Institutional Verification Document V4 Dependent Your 2015 2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says that before

More information

Application for Admission 2016-2017 School Year

Application for Admission 2016-2017 School Year Application for Admission 2016-2017 School Year Mail or deliver applications to: Admissions Office Cristo Rey Columbus High School 400 East Town Street Columbus, Ohio 43215 Phone: (614) 223-9261 x 12008

More information

Application for Admission 2014-2015 School Year

Application for Admission 2014-2015 School Year Application for Admission 2014-2015 School Year Mail or deliver applications to: Admissions Office Cristo Rey Columbus High School 840 West State Street Columbus, Ohio 43222 Phone: (614) 223-9261 x 227

More information

PATIENT INFORMATION. Today s Date. I do not currently carry insurance (initial) Patient s Last Name: Patient s First Name: MEDICAL INSURANCE

PATIENT INFORMATION. Today s Date. I do not currently carry insurance (initial) Patient s Last Name: Patient s First Name: MEDICAL INSURANCE PATIENT INFORMATION Please present a Photo ID and ALL insurance cards to receptionist. If items are not presented, full payment will be due at time of service. Please know ALL Co-Pays are due at time of

More information

Colquitt County Schools Enrollment Packet. Request Forms Middle School

Colquitt County Schools Enrollment Packet. Request Forms Middle School Enrollment Packet Request Forms Middle School Statement of Objection to Use of Social Security Number for Student Identification Request I do not wish to provide the Social Security Number of my child/children.

More information

Monterey County Behavioral Health Policy and Procedure

Monterey County Behavioral Health Policy and Procedure Monterey County Behavioral Health Policy and Procedure 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Policy Number 144 Policy Title Disclosure of Unlicensed Status for License

More information

2014-2015 Independent

2014-2015 Independent 2014-2015 Independent V4-V5 Independent VERIFICATION of High School Completion and Identity Statement of Educational Purpose V4-V5 Your 2014 2015 Free Application for Federal Student Aid (FAFSA) was selected

More information

OFFICE OF COMMON INTEREST COMMUNITY OMBUDSMAN CIC#: DEPARTMENT OF JUSTICE

OFFICE OF COMMON INTEREST COMMUNITY OMBUDSMAN CIC#: DEPARTMENT OF JUSTICE RETURN THIS FORM TO: FOR OFFICIAL USE: (Devuelva Este Formulario a): (Para Uso Oficial) OFFICE OF COMMON INTEREST COMMUNITY OMBUDSMAN CIC#: DEPARTMENT OF JUSTICE (Caso No) STATE OF DELAWARE Investigator:

More information

Student Name Nombre del Estudiante Grade/Grado School/Escuela. Relationship to student Relacion con el estudiante

Student Name Nombre del Estudiante Grade/Grado School/Escuela. Relationship to student Relacion con el estudiante LSNC Summer Camp 2015 Camper Enrollment Form This form must be completed and signed by the parent or guardian of a student enrolling in the Summer Camp STUDENT INFORMATION/INFORMACION DEL ESTUDIANTE Student

More information

Enrollment Forms Packet (EFP)

Enrollment Forms Packet (EFP) Enrollment Forms Packet (EFP) Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documentation in order to complete this step in

More information

SAN DIEGO UNIFIED SCHOOL DISTRICT

SAN DIEGO UNIFIED SCHOOL DISTRICT ADMINISTRATIVE CIRCULAR NO. 18 Office of Special Projects Date: September 18, 2015 SAN DIEGO UNIFIED SCHOOL DISTRICT To: Subject: Department and/or Persons Concerned: Due Date: Reference: Action Requested:

More information

IN THE CIRCUIT COURT OF THE 16 TH JUDICIAL CIRCUIT OF THE STATE OF FLORIDA IN AND FOR MONROE COUNTY ADMINISTRATIVE ORDER _5.014

IN THE CIRCUIT COURT OF THE 16 TH JUDICIAL CIRCUIT OF THE STATE OF FLORIDA IN AND FOR MONROE COUNTY ADMINISTRATIVE ORDER _5.014 IN THE CIRCUIT COURT OF THE 16 TH JUDICIAL CIRCUIT OF THE STATE OF FLORIDA IN AND FOR MONROE COUNTY IN RE: ADMINISTRATIVE ORDER _5.014 THE ESTABLISHMENT OF THE FAMILY COURT SELF-HELP PROGRAM _: NOW, THEREFORE,

More information

Enrollment Application 2014-2015

Enrollment Application 2014-2015 Enrollment Application 2014-2015 Student Name: Date: Current Grade Level: Current School: Date of College Track Presentation: Submit Application by: Checklist of items that must be returned to College

More information

WHAT ARE HEALTH CHECK (MEDICAID) & NC HEALTH CHOICE FOR CHILDREN?

WHAT ARE HEALTH CHECK (MEDICAID) & NC HEALTH CHOICE FOR CHILDREN? HEALTH CHECK (MEDICAID) NC HEALTH CHOICE FOR CHILDREN APPLICATION Free or Low-Cost Health Coverage This application may also be used by parents, caretakers, pregnant women & other adults to apply for Medicaid.

More information

Special Programs. Extended Day/Week Tutorial Program Guidelines

Special Programs. Extended Day/Week Tutorial Program Guidelines 2013 2014 Special Programs Extended Day/Week Tutorial Program Guidelines In Brownsville ISD, every opportunity is extended to help our lowest achieving students become academically successful. In support

More information

Plumbers and Irrigators INSTRUCTIONS -- PLEASE READ CAREFULLY

Plumbers and Irrigators INSTRUCTIONS -- PLEASE READ CAREFULLY Phone:(401)462-8580 Fax: (401)462-8528 www.dlt.ri.gov/profregs Plumbers and Irrigators INSTRUCTIONS -- PLEASE READ CAREFULLY Applications that are incomplete or missing required documents will not be processed

More information

THE CAMBRIDGE PROGRAM POTOMAC SENIOR HIGH SCHOOL CENTER FOR MATH AND PHYSICAL SCIENCES

THE CAMBRIDGE PROGRAM POTOMAC SENIOR HIGH SCHOOL CENTER FOR MATH AND PHYSICAL SCIENCES CENTER FOR MATH AND PHYSICAL SCIENCES Application Checklist : Student s Name: (print) 1. Complete the two-page application form and make sure that the student and parent/guardian both sign and date the

More information

Electrician Application -- INSTRUCTIONS -- PLEASE READ CAREFULLY

Electrician Application -- INSTRUCTIONS -- PLEASE READ CAREFULLY Phone:(401)462-8580 Fax: (401)462-8528 www.dlt.ri.gov/profregs Electrician Application -- INSTRUCTIONS -- PLEASE READ CAREFULLY Applications that are incomplete or missing required documents will not be

More information

N A T I O N A L M I S S I N G P E R S O N S P R O G R A M DNA

N A T I O N A L M I S S I N G P E R S O N S P R O G R A M DNA University of North Texas Center for Human Identification Family Reference Sample Evidence Registration Form Investigating Agency Information Investigating Agency: Agency Case No.: Address: ORI No.: NCIC

More information

CITY OF BUFFALO BYRON W. BROWN MAYOR

CITY OF BUFFALO BYRON W. BROWN MAYOR CITY OF BUFFALO BYRON W. BROWN MAYOR February 1, 2016 Dear Applicant: Thank you for your interest in applying for the 2016 Mayor s Summer Youth Internship Program. Enclosed is an application that must

More information

Y O U T H L E A D. Summer U LEAD Program Application

Y O U T H L E A D. Summer U LEAD Program Application Summer U LEAD Program Application Y O U T H L E A D U LEAD is sponsoring a summer job program for Ramsey County Suburban youth ages 14 to 24. Youth must complete the summer application and complete work

More information

Advanced Dyer Observers Space Science Camp Application (please list only one camper per form)

Advanced Dyer Observers Space Science Camp Application (please list only one camper per form) June 20-24, 2016! Advanced Dyer Observers Space Science Camp Application (please list only one camper per form) Student s name Grade (Fall 2016) 7th 8th School student attends Birthday Gender Adult t-shirt

More information

LOS ANGELES UNIFIED SCHOOL DISTRICT Policy Bulletin

LOS ANGELES UNIFIED SCHOOL DISTRICT Policy Bulletin Policy Bulletin TITLE: NUMBER: ISSUER: Procedures for Requests for Educationally Related Records of Students with or Suspected of Having Disabilities DATE: February 9, 2015 Sharyn Howell, Executive Director

More information

Applying for a Social Security Card is easy AND it is FREE!

Applying for a Social Security Card is easy AND it is FREE! SOCIAL SECURITY ADMINISTRATION Application for a Social Security Card Applying for a Social Security Card is easy AND it is FREE! If you DO NOT follow these instructions, we CANNOT process your application!

More information

DAMAR MEDICAL CENTER, INC

DAMAR MEDICAL CENTER, INC PATIENT INFORMATION TODAY S DATE: / / (INFORMACION DEL PACIENTE) MES/DIA /AÑO: / / PATIENT S NAME: NOMBRE Y APELLIDO: D.O.B.: / / FECHA DE NACIMIENTO / / ADDRESS: CITY: ZIP CODE DIRECCION CIUDAD: CODIGO

More information

CHARLOTTE-MECKLENBURG SCHOOLS

CHARLOTTE-MECKLENBURG SCHOOLS STUDENT PLACEMENT ENROLLMENT INFORMATION The following documents are required for enrollment: q Student Enrollment Form q Original Certified copy of student s birth certificate - hospital, souvenir or

More information

Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL (SEGURO SOCIAL)

Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL (SEGURO SOCIAL) 7887 North Kendall Drive Suite 210 Miami, Florida 33156 305.598.1555 office 305.598.1155 fax www.vascularandspine.com Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL

More information

Application for prospective foster, respite, kinship and adoptive families

Application for prospective foster, respite, kinship and adoptive families Print Submit via email Foster Care Respite Kinship Adoption Application for prospective foster, respite, kinship and adoptive families Before submitting, please ensure that all applicants have signed and

More information

High School Common Application 2013-2014

High School Common Application 2013-2014 High School Common Application 2013-2014 KIPP Houston High School 10711 KIPP Way Drive Houston, TX 77099 Lara Wheatley, School Leader lwheatley@kipphouston.org (832) 328-1082 KIPP Sunnyside High School

More information

Educational Talent Search

Educational Talent Search Dear Parent(s), Educational Talent Search (ETS) is a project funded by the U. S. Department of Education and is administered by Diablo Valley College (DVC). The purpose of this project is to encourage

More information

1530 E. Lincoln Highway, Coatesville, PA 19320 (610) 383-6800 fax: (610) 383-0694

1530 E. Lincoln Highway, Coatesville, PA 19320 (610) 383-6800 fax: (610) 383-0694 HEAD START A Chester County Intermediate Unit Program 1530 E. Lincoln Highway, Coatesville, PA 19320 (610) 383-6800 fax: (610) 383-0694 Dear Parent or Guardian, Thank you for your interest in the Head

More information

ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC.

ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC. .Specwtlfczlkuj Ut Pedlfltric. physical, occ.upflt«>ithl, Speech Therapy sen/tees PATIENT INFORMATION Patient Name (Nombre del paciente] Date of Birth (Fecha de nacimiento] Address (Direccion] City [Cuidad]

More information

Impreso de Solicitud / Application Form

Impreso de Solicitud / Application Form Fotografía/ Photograph Impreso de Solicitud / Application Form Sistema Europeo de Transferencia de Créditos / European Credit Transfer System Datos del estudiante / Student s personal data Apellido 1 /

More information

LOS ANGELES UNIFIED SCHOOL DISTRICT BULLETIN

LOS ANGELES UNIFIED SCHOOL DISTRICT BULLETIN TITLE: NUMBER: ISSUER: Parental Exception Waivers: Procedures and Guidelines for Requesting Alternative Programs for English Learners, K-12 Dr. Judy Elliot, Chief Academic Officer Instructional Services

More information

LOS ANGELES UNIFIED SCHOOL DISTRICT POLICY BULLETIN

LOS ANGELES UNIFIED SCHOOL DISTRICT POLICY BULLETIN TITLE: NUMBER: ISSUER: Guidelines for the Use of Audiovisual Materials Not Owned, Broadcast, or Recommended by the District BUL-5210 Judy Elliott, Chief Academic Officer ROUTING Local District Superintendents

More information

Students BP 5132.1 MANDATORY UNIFORMS. Background

Students BP 5132.1 MANDATORY UNIFORMS. Background Students BP 5132.1 MANDATORY UNIFORMS Background Over the past several years, many parents and community members have urged the district to adopt a mandatory uniform policy as a means of enhancing and

More information

Venezuela Business visa Application

Venezuela Business visa Application Venezuela Business visa Application Please enter your contact information Name: Email: Tel: Mobile: The latest date you need your passport returned in time for your travel: Venezuela business visa checklist

More information

PATIENT'S INFORMATION REGISTRATION SHEET / INFORMACION DEL PACIENTE

PATIENT'S INFORMATION REGISTRATION SHEET / INFORMACION DEL PACIENTE DAN S. COHEN, M.D PATIENT'S INFORMATION REGISTRATION SHEET / INFORMACION DEL PACIENTE PLEASE PRINT CLEARLY / POR FAVOR ESCRIBA LEGIBLEMENTE TODAY S DATE / FECHA DE HOY: PATIENT'S NAME/NOMBRE DEL PACIENTE:

More information

Send your complete application via U.S. Mail to: Mrs. Annette Castillo, Principal

Send your complete application via U.S. Mail to: Mrs. Annette Castillo, Principal San Antonio Independent School District Mission Statement To graduate all of our students and prepare them for success in higher education. Fox Tech High School for Health and Law Professions Student Profile

More information

FNRE Scholarship Application

FNRE Scholarship Application East Holly Avenue, Box 56! Pitman, New Jersey 08071-0056 (856)256-2343 FAX (856)589-7463 FNRE Scholarship Application Foundation for Neonatal Research and Education (FNRE) (Instructions--please read prior

More information

CA Dream Application References

CA Dream Application References CA Dream Application References 2014 California High School Counselor Workshop Guide Page 171 California Nonresident Tuition Exemption For Eligible California High School Graduates (The law passed by

More information

Field Experience Handbook: Practicum and Internship

Field Experience Handbook: Practicum and Internship Field Experience Handbook: Practicum and Internship For Students, Site Supervisors and School Counseling Faculty School Counseling Program Department of Educational Psychology College of Education University

More information

High School Dual Enrollment Admission Application Form

High School Dual Enrollment Admission Application Form High School Dual Enrollment Admission Application Form Dual Enrollment: A Head Start on College. Mount Wachusett Community College offers multiple concurrent enrollment programs. Whether in high school

More information

Youth Employment Services (YES) Program Application

Youth Employment Services (YES) Program Application Employment & Training Department Central Council Tlingit and Haida Indian Tribes of Alaska 320 West Willoughby Avenue, Suite 300 Juneau, Alaska 99801 Phone: 907.463.7792 or 800.344.1432 Ext. 7792 Fax:

More information

FISD Field Study Guidelines and Procedures

FISD Field Study Guidelines and Procedures 600 South Bois d Arc * Forney, Texas 75126 * 972-564-4055 * Fax: 972-564-7007 * www.forneyisd.net FISD Field Study Guidelines and Procedures Note: FISD Field Study Request Forms must be submitted to the

More information

High School Common Application 2016-2017

High School Common Application 2016-2017 High School Common Application 2016-2017 KIPP Houston High School 10711 KIPP Way Drive Houston, TX 77099 Lara Wheatley, School Leader lwheatley@kipphouston.org (832) 328-1082 KIPP Sunnyside High School

More information

Application for SERVICES IN YOUR HOME

Application for SERVICES IN YOUR HOME Application for SERVICES IN YOUR HOME This is an application for Medical Assistance benefits for services in your home. If you need this application in another language or someone to interpret, please

More information

James B. Rolle Elementary 21 st CCLC Before and After School Program

James B. Rolle Elementary 21 st CCLC Before and After School Program James B. Rolle Elementary 21 st CCLC Before and After School Program August 26, 2014 Morning Session: 7:15 AM 8:15 AM Afternoon Session: 3:30 PM 4:45 PM James B. Rolle 21 ST CCLC Before and After School

More information

Wallace Community College Dual Enrollment Program Application

Wallace Community College Dual Enrollment Program Application Wallace Community College Dual Enrollment Program Application Checksheet for Dual Enrollment Application Packet Application MUST BE COMPLETE or it will not be accepted for processing! USE A PEN NO PENCIL!

More information

AUXILIARY APPLICATION

AUXILIARY APPLICATION PLEASE PRINT GREGORY-PORTLAND INDEPENDENT SCHOOL DISTRICT Office Use ONLY HUMAN RESOURCES Date Received: 608 COLLEGE STREET PORTLAND, TX 78374 (361) 777-1091, Ext. 1020 Date Approved: AUXILIARY APPLICATION

More information

POLICY BULLETIN #06-95-ELI

POLICY BULLETIN #06-95-ELI \FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner

More information

PERRIS UNION HIGH SCHOOL DISTRICT FREE Tutoring for your child!

PERRIS UNION HIGH SCHOOL DISTRICT FREE Tutoring for your child! PERRIS UNION HIGH SCHOOL DISTRICT 2016-2017 FREE Tutoring for your child! El Departamento de Servicios Educativos Dear Parent/Guardian: The Perris Union High School District is dedicated to ensuring that

More information

Student Name High School Period Preference ( ) AM 7-11 ( ) PM 12-4

Student Name High School Period Preference ( ) AM 7-11 ( ) PM 12-4 DATE PACKET RECEIVED INITIALS EVIT COSMETOLOGY & AESTHETICS PACKET Thank you for applying to the EVIT Cosmetology program. Your packet must contain all of the following items and be delivered to the EVIT

More information

Renewal Form. www.upmchealthplan.com/upmcforkids

Renewal Form. www.upmchealthplan.com/upmcforkids Renewal Form www.upmchealthplan.com/upmcforkids There are three easy ways to renew CHIP coverage! To keep CHIP coverage, you can: 1. RENEW ONLINE USING COMPASS: (If you apply online, most of your information

More information

PWB Management Corporation 3092 Hull Avenue, Bronx, NY 10467 Tel:(718) 519-6900 Fax: (718) 519-6904

PWB Management Corporation 3092 Hull Avenue, Bronx, NY 10467 Tel:(718) 519-6900 Fax: (718) 519-6904 PWB Management Corporation 3092 Hull Avenue, Bronx, NY 10467 Tel:(718) 519-6900 Fax: (718) 519-6904 Dear Applicant, Enclosed is our apartment application which must be totally completed prior to submission.

More information

* Teacher recommendation and/or approval required.

* Teacher recommendation and/or approval required. Rubén Darío Middle Community School Student Registration Form 2015-2016 Grade 7 Regular Program ESE Gifted ESOL 1 2 3 4 Reading FCAT Level (2014) Mathematics FCAT Level (2014) Name: I.D. # Seventh grade

More information

FREE Tutoring for your child!

FREE Tutoring for your child! Educational Services presents 2014-2015 FREE Tutoring for your child! If your child attends one of the following schools AND receives Free or Reduced priced meals they may be eligible for FREE Tutoring.

More information

Enrollment Forms Packet (EFP)

Enrollment Forms Packet (EFP) Enrollment Forms Packet (EFP) Please review the information below. Based on r student(s) grade and applicable circumstances, are required to submit documentation in order to complete this step in the enrollment

More information

PATIENT INFORMATION PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # CELLULAR # RELIGION:

PATIENT INFORMATION PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # CELLULAR # RELIGION: NEW PATIENT INFORMATION PRIMARY CARE DOCTOR: PCP # FAX # PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # _ CELLULAR # RELIGION: STREET ADDRESS:

More information

Just The Beginning A Pipeline Organization Summer Legal Institute D.C.-Maryland-Virginia

Just The Beginning A Pipeline Organization Summer Legal Institute D.C.-Maryland-Virginia Just The Beginning A Pipeline Organization Summer Legal Institute D.C.-Maryland-Virginia Monday, July 7-Friday, July 11, 2014 Hosted by Howard University School of Law The Summer Legal Institute (SLI)

More information

Application for Admission (Supplement Material Packet)

Application for Admission (Supplement Material Packet) Application for Admission (Supplement Material Packet) WELCOME Dear Applicant, Thank you for your interest in Year Up Professional Training Corps (PTC) National Capital Region (NCR) at Woodbridge! Please

More information

2016 State Funded Youth Employment Program

2016 State Funded Youth Employment Program 2016 State Funded Youth Employment Program APPLICATION OF INTEREST Completion of this application does not guarantee a slot in the program. This program is currently PENDING funding. Youth will be notified

More information

Application for Graduate Admission

Application for Graduate Admission Application for Graduate Admission Before you begin International students should visit http://www.nmsu.edu/~ip/ for application procedures. ENROLLMENT INFORMATION Semester when you plan to start Fall

More information

Nicholas C. Lambrou, M.D., LLC 6200 Sunset Drive, STE 502, Miami, Florida 33143 4306 Alton Road, 3 rd Floor, Miami Beach, Florida 33140

Nicholas C. Lambrou, M.D., LLC 6200 Sunset Drive, STE 502, Miami, Florida 33143 4306 Alton Road, 3 rd Floor, Miami Beach, Florida 33140 DATE: Fecha: DRIVER'S LICENSE# Numero De Licencia De Conducir: PATIENT NAME: BIRTH DATE: Nombre del paciente Fecha de nacimiento HOME ADDRESS: SOCIAL SECURITY: Direccion del hogar: Seguro Social CITY/STATE/ZIP:

More information

Pipefitters, Refrigeration Techanicians, Sheet Metal and Fire Protection Sprinkler Fitter Application INSTRUCTIONS -- PLEASE READ CAREFULLY

Pipefitters, Refrigeration Techanicians, Sheet Metal and Fire Protection Sprinkler Fitter Application INSTRUCTIONS -- PLEASE READ CAREFULLY Phone:(401)462-8580 Fax: (401)462-8528 www.dlt.ri.gov/profregs Pipefitters, Refrigeration Techanicians, Sheet Metal and Fire Protection Sprinkler Fitter Application INSTRUCTIONS -- PLEASE READ CAREFULLY

More information

REDETERMINATION BY MAIL PACKET

REDETERMINATION BY MAIL PACKET REDETERMINATION BY MAIL PACKET Dear Parent/Guardian: You have been selected to submit your childcare application by mail. Enclosed are all the forms you need to complete and sign. These forms are also

More information

LOS ANGELES UNIFIED SCHOOL DISTRICT BULLETIN

LOS ANGELES UNIFIED SCHOOL DISTRICT BULLETIN TITLE: NUMBER: ISSUER: Parental Exception Waivers: Procedures and Guidelines for Requesting Alternative Programs for English Learners, K-12 BUL-4153.1 Jaime R. Aquino, Ph.D. Deputy Superintendent of Instruction

More information

105-01 Compliance with the National Voter Registration Act of 1993

105-01 Compliance with the National Voter Registration Act of 1993 Connecticut WIC Program Manual Federal Fiscal Year 2016 Section: Voter Registration 105-01 Compliance with the National Voter Registration Act of 1993 Connecticut WIC Program Manual WIC 105-01 SECTION:

More information

T.E.A.C.H. Early Childhood WISCONSIN Scholarship Application

T.E.A.C.H. Early Childhood WISCONSIN Scholarship Application T.E.A.C.H. Early Childhood WISCONSIN Scholarship Application Instructions 1 Fill out application completely and submit all items listed below. If information is missing or not all questions on the application

More information

New Jersey Cares for Kids Child Care Subsidy Program (NJCK)

New Jersey Cares for Kids Child Care Subsidy Program (NJCK) New Jersey Cares for Kids Child Care Subsidy Program (NJCK) Executive Director Joan Lorah, LCSW The child care subsidy through the NJCK Program will assist you to pay for child care for infants, toddlers,

More information

Boston Area Health Education Center

Boston Area Health Education Center Boston Area Health Education Center Youth to Health Careers Program Application Checklist Due March 12th, 2014 Full Name: School: Best Phone to Contact You: Grade: The Youth to Health Careers (Y 2 HC)

More information

PROGRAM APPLICATION FOR GATEWAY TO COLLEGE ADMISSION

PROGRAM APPLICATION FOR GATEWAY TO COLLEGE ADMISSION PROGRAM APPLICATION FOR GATEWAY TO COLLEGE ADMISSION Please read the entire application carefully before completing. Print clearly. Use a black or blue ink pen. Only complete applications will be considered.

More information

2016 APPLICATION. Embarking on 25 years of preparing young people for careers and getting them ready for college

2016 APPLICATION. Embarking on 25 years of preparing young people for careers and getting them ready for college 2016 APPLICATION Embarking on 25 years of preparing young people for careers and getting them ready for college SLIP IS HERE... To provide inspiration, support, professional development, and training to

More information

Please note: We are accepting applications for 1-4 bedroom apartments only.

Please note: We are accepting applications for 1-4 bedroom apartments only. Page 1 Gardens at SouthBay Preliminary Application 6720 S. Louis Ave, Tampa, FL 33616 PLEASE RETURN APPLICATION MONDAY THURSDAY 9AM 6PM POR FAVOR DE REGRESAR LA APLICACIÓN DE LUNES A JUEVES DE 9AM A 6PM

More information

PARTICIPANT APPLICATION Page 1 of 3 Revised September 2015

PARTICIPANT APPLICATION Page 1 of 3 Revised September 2015 Page of 3 Revised September 05 Student Information Please print in BLACK or BLUE ink. Last Name First Name Middle Name Sex Male of Birth (mm/dd/yyyy) Student School ID # Social Security Number Female Current

More information

Daytime Telephone Number (Número Telefónico) Date of Application (Fecha) County (Condado)

Daytime Telephone Number (Número Telefónico) Date of Application (Fecha) County (Condado) Borough of Matawan - Dept. of Vital Statistics $10.00 p/copy 201 Broad Street, Matawan, NJ 07747 Phone 732-566-3898 x625 Fax 732-566-0036 APPLICATION FOR A NON-GENEALOGICAL CERTIFICATION OR CERTIFIED COPY

More information

TEXAS ENGINEERING FOUNDATION 2015-2016 Scholarship Application for Graduating Texas High School Seniors

TEXAS ENGINEERING FOUNDATION 2015-2016 Scholarship Application for Graduating Texas High School Seniors TEXAS ENGINEERING FOUNDATION 2015-2016 Scholarship Application for Graduating Texas High School Seniors Application deadline is January 8, 2016 The chapters of the Texas Society of Professional Engineers

More information

2. Please read carefully, print neatly and complete the entire Enrollment Form, including the Enrollment Checklist.

2. Please read carefully, print neatly and complete the entire Enrollment Form, including the Enrollment Checklist. First Health Part D Medicare Prescription Drug Plan (PDP) Individual Enrollment Form Instructions Follow these easy instructions to enroll in First Health Part D. If you have any questions, please call

More information

APPLICATION DEADLINE: Friday, April 17, 2015 by 5pm

APPLICATION DEADLINE: Friday, April 17, 2015 by 5pm SUMMER 2015 APPLICATION Thank you for your interest in applying to San Francisco YouthWorks. Please contact us at 415-202-7911 or info@sfyouthworks.org with any questions. APPLICATION DEADLINE: Friday,

More information

Summer Reading and Class Assignments 2014-2015 Rising Seniors

Summer Reading and Class Assignments 2014-2015 Rising Seniors Student Name: Summer Reading and Class Assignments 2014-2015 Rising Seniors JIMMY CARTER EARLY COLLEGE HIGH SCHOOL LA JOYA INDEPENDENT SCHOOL DISTRICT To the Class of 2015: Jimmy Carter Early College High

More information

FORMULARIO DE INSCRIPCIÓN

FORMULARIO DE INSCRIPCIÓN INFORMACIÓN PERSONAL PERSONAL DATA APELLIDOS / SURNAME MBRE / NAME FECHA DE NACIMIENTO (D/M/A) / BIRTHDATE (D/M/Y) NACIONALIDAD / CITIZENSHIP NÚMERO DE PASAPORTE / PASSPORT NUMBER HOMBRE / MALE MUJER /

More information

Watsonville & Silicon Valley College Success Scholarship 2012 Application for New Scholarships

Watsonville & Silicon Valley College Success Scholarship 2012 Application for New Scholarships Watsonville & Silicon Valley College Success Scholarship 2012 Application for New Scholarships Scholarship Awards $1,000 to $5,000 awarded for the 2012-13 academic year Scholarships may only be used in

More information

Boston Area Health Education Center

Boston Area Health Education Center Boston Area Health Education Center Youth to Health Careers Program Full Name: School: Application Checklist Due March 16th, 2016 Best Phone to Contact You: Please Circle: Home Cell Grade: The Youth to

More information

2. Statement of Acknowledgment and Consent to Conditions of Trip (Adult not an employee of or student in the San Diego Unified School District)

2. Statement of Acknowledgment and Consent to Conditions of Trip (Adult not an employee of or student in the San Diego Unified School District) Office of the Superintendent FIELD TRIP PLANNING PACKET SINGLE DAY District Procedure No. 4585 Contents of packet 1. Site-Approval Checklist for Single-Day Field Trips 2. Statement of Acknowledgment and

More information

A String Theory School

A String Theory School A String Theory School www.stringtheoryschools.com West Campus Vine Street Campus East Campus 2600 South Broad Street 1600 Vine Street 2407 South Broad Street Philadelphia, PA 19145 Philadelphia, PA 19102

More information

ANSEP SUMMER BRIDGE APPLICATION FORM 2015

ANSEP SUMMER BRIDGE APPLICATION FORM 2015 APPLICATION FORM 2015 What is the ANSEP Summer Bridge? The ANSEP Summer Bridge focuses on developing students academically, socially and professionally for college and careers. Summer Bridge students enroll

More information

Running Start Program Application Information

Running Start Program Application Information Running Start Program Application Information Running Start for High School Seniors Running Start is a program offered at the Community College of Rhode Island for high school students who demonstrate

More information

WHITTIER COLLEGE. Application for Admission Teacher Credential Program. Department of Education & Child Development

WHITTIER COLLEGE. Application for Admission Teacher Credential Program. Department of Education & Child Development WHITTIER COLLEGE Department of Education & Child Development Application for Admission Teacher Credential Program 13406 E. Philadelphia Street P.O. Box 634 Whittier, CA 90608 562-907- 4248 Fax: 562-464-

More information

Carroll College Matched Education Savings Account Application

Carroll College Matched Education Savings Account Application PERSONAL INFORMATION Name: Social Sec. No. (last four digits): Gender: Female Male Date of Birth: / / Ethnicity: African American Caucasian Latino or Hispanic Asian, Pacific Islander Native American Other

More information

2015 SCHOLARSHIP APPLICATION PROCEDURES AND CHECKLIST

2015 SCHOLARSHIP APPLICATION PROCEDURES AND CHECKLIST 2015 SCHOLARSHIP APPLICATION PROCEDURES AND CHECKLIST ELIGIBILITY REQUIREMENTS Full-time admission to a two-year or four-year college, university or trade/technical school; GPA of at least 2.5 or B-; Resident

More information

TROY CITY SCHOOL DISTRICT 475 First Street Troy, New York

TROY CITY SCHOOL DISTRICT 475 First Street Troy, New York TROY CITY SCHOOL DISTRICT 475 First Street Troy, New York 12180 www.troycsd.org Registration Checklist for Preschool Welcome to Troy Schools! In order to register your child, a parent or guardian must

More information

PROCEDURES FOR COMPLETION OF WORK COMP CLAIMS PAPERWORK

PROCEDURES FOR COMPLETION OF WORK COMP CLAIMS PAPERWORK PROCEDURES FOR COMPLETION OF WORK COMP CLAIMS PAPERWORK Please complete the attached packet in the following manner. Forms must be completed within 24 hours of reporting the injury/illness to supervisor.

More information

Wesleyan Pre-College Access Program

Wesleyan Pre-College Access Program Wesleyan Pre-College Access Program What is the Pre-College Access Program? Wesleyan University s Pre-College Access Program is a comprehensive program developed to enhance the academic skills and preparation

More information

SUMMER PROGRAM APPLICATION

SUMMER PROGRAM APPLICATION www.iefl.org SUMMER PROGRAM APPLICATION LATINO STUDENT LEADERSHIP CONFERENCE July 29 August 3, 2012 ASTROCAMP IDYLLWILD, CALIFORNIA MAY BE DUPLICATED INLAND EMPIRE Dear Student: If you are an eighth- or

More information

Submit your originals and the photocopies to:

Submit your originals and the photocopies to: Your Name: Available Institute Scholarships: Please specify which scholarship program(s) you are applying for by placing a check in the appropriate box next to the program. You are eligible to apply for

More information

2013 Health Careers Summer Camp Application Checklist

2013 Health Careers Summer Camp Application Checklist 2013 Health Careers Summer Camp Application Checklist Please use this checklist to confirm that all required documents have been obtained and completed before mailing your complete application packet to

More information

STUDENT APPLICATION FORM 2015

STUDENT APPLICATION FORM 2015 Camp Information: STUDENT APPLICATION FORM 2015 July 5 - July 10 and July 12 - July 17, 2015 Engineering Your Place in Space The ExxonMobil Bernard Harris Summer Science Camp (EMBHSSC) is organized to

More information

Please select one or more race which best describe the child being registered: American Indian or Alaska Native Asian Black or African American

Please select one or more race which best describe the child being registered: American Indian or Alaska Native Asian Black or African American Somers Central School District P. O. Box 620 Lincolndale, New York 10540 Student ID# Family ID# (office use only) Date: STUDENT REGISTRATION DATA PACKET Welcome to the Somers Central School District. All

More information