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1 READINESS htp:/apps.bexar.org/electionsearch/electionsearch.aspx?psearchtab=3

2 Family Service Association of San Antonio, Inc. Universal Enrollment Form Before submitting your application, please make sure you have the following documents included: Complete Application Copy of Social Security Card Proof of Residence (light bill, water bill) Liability Form Complete Criminal Background Check form with student and Parent Signature Media Release Form (optional) Medical Release (Same page as media release, NOT optional) W9 Questions about application process: *** If you have further questions, us at Turn in applications to the front office of The Neighborhood Place Located at 3014 Rivas, San Antonio, TX 78228

3 PARENT/GUARDIAN CONTACT INFORMATION Parent/Guardian Name: Home Phone: Work Phone: AGREEMENT INCLUDING RELEASE AND LIABILITY INDEMNIFICATION In consideration of participant being allowed to participated in the Youth Career Opportunity Program, the undersigned hereby releases Family Service Association of San Antonio, Inc. (Family Service), its employees, agents, and partnering agencies from any action, claim or demand for personal injury or property loss from or due to any negligent act or omission of Family Service, its employees, agents and/or partnering organizations who are participating in the Youth Career Opportunity Program. This release shall have no effect with regard to damages caused by the parties gross negligence. Permission is given for any emergency medical treatment, operation or anesthesia, which might become necessary. I agree to be responsible for the expense of medical treatment or service. WHEREAS, FAMILY SERVICE, consents and agrees to permit hereinafter YOUTH, to participate in the Youth Career Opportunity Program, subject to the adherence of the YOUTH to any provisions set out in the rules and regulations of Family Service, and the parent or guardian of YOUTH, hereinafter PARENT or GUARDIAN, consents to YOUTH participating in the Youth Career Opportunity Program. NOW, THEREFORE, for and in consideration of the premises and the mutual promises, covenants, and agreements set forth in this Agreement, FAMILY SERVICE, PARENT OR GUARDIAN, and YOUTH agree that FAMILY SERVICE, its employees, agents and/or partnering agencies, shall not be liable or responsible for, and shall be SAVED, HELD HARMLESS, RELEASED and INDEMNIFIED by PARENT or GUARDIAN and YOUTH from and against any and all suits, actions, losses, damages, claims or liability of any character, type, or description, including but not limited to all expenses of litigation, court costs, and attorney fees for injury or death to any person, or injury to any property received or sustained by any person or persons or property arising out of, or occasioned by, directly or indirectly, the participation of YOUTH in the Youth Career Opportunity Program including claims and damages arising in whole or in part from the negligence of FAMILY SERVICE, its employees, agents or partnering agencies. IT IS THE EXPRESS INTENT OF THE PARTIES TO THIS AGREEMENT THAT THE INDEMNITY PROVIDED FOR IN THIS AGREEMENT IS AN INDEMNITY EXTENDED BY PARENT OR GUARDIAN AND YOUTH TO INDEMNIFY AND PROTECT FAMILY SERVICE FROM ANY AND ALL CLAIMS OR ACTIONS, AS SET FORTH ABOVE, OF ANY KIND, ARISING DIRECTLY OR INDIRECTLY FROM THE PARTICIPATION OF YOUTH IN The Youth Career Opportunity Program, REGARDLESS OF WHETER SUCH CLAIMS OR ACTIONS ARE FOUNDED IN WHLE OR IN PART UPON ALLEGED NEGLIGENCE OF FAMILY SERVICE, ITS REPRESENTATIVES, AGENTS OR EMPLOYEES. In making this Agreement, PARENT or GUARDIAN and YOUTH rely wholly upon their own judgment, belief and knowledge and have not been influenced to any extent whatsoever by any representations or statements not contained in this Agreement. SIGNATURE OF YOUTH PARTICIPANT: DATE: SIGNATURE OF PARENT/GUARDIAN of PARTICIPANT: DATE:

4 Family Service Association of San Antonio, Inc. Universal Enrollment Form Family Service has been providing services that strengthen families since The information below will be kept strictly confidential but is essential for Family Service to provide relevant and quality services to you and your family. (Please Print) Enrollment Date: Location: Name: Last First Middle Initial DOB: Gender: Male Female Social Security Number (last four)/itin: Address: (Street) City: State: Zip: Phone: Ok to leave a message yes Best way to contact you: Home Phone Cell Phone Call or Text : Ethnic Origin or Race: (please mark all that apply) Black or African American Asian Hispanic or Latino Native American White Native Hawaiian/Pacific Islander Other Primary Language Spoken: How did you learn about Family Service? Have you ever received services from our agency before? Yes If yes, what type of services? Household Type: Single Parent household Two Parent household Guardian/Foster Children in Household Marital Status: Married Divorced Separated Single Widowed Common-Law Partner Family Annual Income Range: Less than $5,000 $5,000-$9,999 $10,000-$14,999 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000 + Annual Income: Employment Status: Employed Student Not Employed Employer 2 nd Parent if applicable: Employed Student Not Employed Employer In the past year have you been a Seasonal Migrant Worker? Yes 1

5 Family Service Association of San Antonio, Inc. Universal Enrollment Form Highest Grade / Education Level Completed: Did Not Graduate High School High School Graduate Some College College Graduate 2 nd Parent if applicable: Did Not Graduate High School High School Graduate Some College College Graduate Do you receive any of the following: CCS SNAP (Food Stamps) TANF WIC Medicaid CHIP Head Start Services Earned Income Tax Credit Parenting Education Affordable Health Care Do you have Health Insurance Yes If Yes, Insurance Company Is your insurance provided by your employer? Yes Are you a Military Family? Yes If yes, Rank Grade Branch Is there a Veteran in your immediate family? Yes Housing Do you: Own Rent Shared Housing with friends/relatives Public Housing Temporary ( shelter, temporary with friends/relatives) Homeless Indicate any possible immediate needs for you or your family [Please check all that apply]: Housing Food/Nutrition Job Training College Readiness Counseling Services Victim Assistance Home Care Services Child Care/Early Childhood Education Utilities/Bill Assistance Public Benefits Application Assistance Adult Ed/GED Special Needs Substance Abuse School Failure/Youth Development Other Do you have any of the following Presenting concerns [Please check all that apply]: Family Issues Divorce Child Custody Family Violence Marital/Couple Parent/Child Academic/School Alcohol/Drugs Grief/Loss Job Related Legal Issues Victim of Crime Personal/Emotional Sexual Abuse Financial Planning/Money Management Other Your Household Composition: (If you need more space please use the back of this page) Name Relationship to you DOB Age Gender Ethnicity SS#/ITIN (last four) 2

6 Family Service Association of San Antonio, Inc. Universal Enrollment Form If your child or children is/are school aged, please list the school and district they attend: School: District: Grade: School: District: Grade: School: District: Grade: School: District: Grade: Do you have internet access? Yes If Yes, In what form? (please check all that apply) Home Computer Tablet Smart Phone Gaming System Library Community Center Family/Friend/Neighbor Do you have your own transportation? Yes If No, do you use public transportation? Daily Often Sometimes Never How many transfers did it take you to reach our office? Person to Call In Case of an Emergency: Name: Relationship: Phone: Please list any life threatening allergens (Food/Insect/Environmental/Medication): Are you a Registered Sex Offender? Yes CERTIFICATION, I certify that the information I have provided on this application for services is true and complete to the best of my knowledge: Family Service Staff Member: For Office Use: Level 1: Level 2: Level 3: Assigned Counselor/Therapist: Date of Appt: District: Congressional Senate Representative City Council 3

7 Parent/Guardian Responsibility Application: I hereby understand that my son/daughter s submission of this application does not guarantee acceptance into the Career Opportunity Program and therefore consent to allowing my son/daughter to be interviewed by Family Service Association staff and/or it s partnering agencies to ensure appropriate placement for a potential internship opportunity. Transportation: I hereby consent that I will provide or seek reliable transportation for my son/daughter who is enrolled in the Career Opportunity Program to and from all mandatory trainings and their internship site throughout the duration of the program or I will request buss passes my son/ daughter is eligible to receive free of charge from Family Service Association. I also understand that my son or daughter may not be placed in a location/ internship site based on my residence. My son/ daughter will be placed at any site location available. Career Training and Development Consent: I hereby consent that as part of this Career Opportunity Program my son/daughter is required to participate in career development trainings, financial literacy sessions, and/or college campus tours. Places may include but are not limited to job fairs, faux job interviews, and career skill and training locations. Criminal Background Check I hereby consent to allowing Family Service Association to conduct a criminal background check on my son/daughter who is participating in the Youth Career Opportunity Program. Savings Account: I hereby understand that as part of this Youth Career Opportunity Program I will assist my youth in opening a required savings account prior to employment with a bank provided by the agency, and save 10% of his/her stipend from the summer internship. My youth will need to provide documentation (i.e. bank statement) to Family Service staff, showing that they do in fact have a savings account under their name, and have deposited at least 10% of their internship earnings into their saving account. *Documentation must have the word Saving on the form. Work Requirement: I hereby consent for my son/daughter to work the necessary job hours to make the most success out of this internship opportunity. Work days may range from Sunday through Saturday and the work day may begin at 7 a.m. in the morning, and can possibly end late in the evening. I understand that the work week will be an average of 20 hours a week, and the internship will be six weeks long. If selected I understand that my son/daughter will coordinate with their site supervisor to arrange an appropriate work schedule and will be required to work the necessary hours prearranged in order to fulfill job expectations. I understand that Family Service Association along with collaborating companies have the right to terminate my son/daughter from their internship for unexcused absences, tardiness, inappropriate misconduct, and/or failure to comply with the policy and protocols of their internship placements. Work Attire: I hereby consent that my son/daughter will dress appropriately for all job duties. I understand that my son/daughter will be expected to work professionally, and their attire is important in the work place. Stipend: I hereby understand that my son/daughter will be paid $7.25 an hour for an average 20 hour work week during the 6 week program. I understand that my son or daughter will be paid monthly. I understand that my son/daughters will be paid for completing the mandatory training hours. I understand the stipend received will not be taxed and therefore I expect to receive a 1099 form from Family Service Association to submit for tax preparations, legal documentation to IRS or/and appropriate authorities by January 31, PARENT/GUARDIAN OF PARTICIPANT PARENT/GUARDIAN OF PARTICIPANT PARENT/GUARDIAN OF PARTICIPANT PARENT/GUARDIAN OF PARTICIPANT PARENT/GUARDIAN OF PARTICIPANT PARENT/GUARDIAN OF PARTICIPANT PARENT/GUARDIAN OF PARTICIPANT PARENT/GUARDIAN OF PARTICIPANT Youth Participant Disclaimer and Signature I certify that my answers above are true and complete to the best of my knowledge. If this application leads to an internship, I understand that false or misleading information in my application or interview may result in my release. Signature PARENT/GUARDIAN Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. If this application leads to an internship, I understand that false or misleading information in my application or interview may result in my son/daughter s release. I understand that I can contact Family Service Association to assist me with the clarification/explanation of this application that is to be submitted. Signature Date Date

8 CONSENT FOR CRIMINAL BACKGROUND HISTORY/ SEX OFFENDER CHECK AUTHORIZATION/ WAIVER/ INDEMNITY I hereby give my permission for FAMILY SERVICE ASSOCIATION OF SAN ANTONIO, INC. to obtain information relating to my criminal history/sex offender record through PublicData.com. The criminal history/sex offender record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudication and delinquent conduct committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/ volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history/ sex offender records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history/sex offender as received by PublicData.com and a procedure is available for clarification, if I dispute the record as received. I, the undersigned, do, for myself my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify Family Service Association and each of their officers, directors, employees and agents and hold them harmless from and against any and all causes of actions, suits, liabilities, cost debts, and sums of money, claims and demands whatsoever, (including claims for the negligence, gross negligence, and/ or strict liability of Family Service Association) and any and all related attorneys fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/ staff member. Name(Print): Last First Middle Position w/ Agency: Date of Birth: Place of Birth: TX Driver s License#: Social Security#: Home Address: City, State & Zip: Phone:_( ) Height: Weight: Eye Color: Hair Color: Race: Sex: I certify that the above information is true and correct. Applicant Signature Date: Parent Signature Date:

9

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