Youth Employment Application Please complete this form below as accurately as possible. Personal InformationName* First Middle Last Suffix Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number*Date of Birth* MM slash DD slash YYYY Sex*MaleFemalePhone*Alternate PhoneEmail Are you a U.S. Citizen?*YesNoEthnicity White (Non-Hispanic) African American Hispanic or Latino Native Alaskan/American Indian Asian Other Choose not to identifyThis question is voluntary. Information will be kept confidential and is intended solely for record keeping purposes and affirmative action requirements.Please select the services you are interested in.* Summer Youth Employment/Work Experience Program Out-of-School Basic Skills/TASC prep/Work Experience In-School Employment Services and ProgramsEducationPlease select your highest level of education completed.* High School Graduate GED/TASC College Student None of the AboveHighest Grade Completed*Current Grade*Please write N/A if not applicable.If you are attending a secondary, vocational, technical, or academic school full-time or if you are between terms do you plan on returning?YesNoName of School you are presently attendingAre you receiving Special Education or Resource Room assistance?YesNoEmployment HistoryAre you currently employed?*YesNoName of Employer:*Start Date* DD slash MM slash YYYY Employment HistoryEmployerStart DateEnd DateAddressJob TitleWage (per hr/week/month/year)Reason for Leaving Please list any additional skills here:EligibilityDisability Status*DisabledNot DisabledPlease check all that apply.* Select All Pregnant or Parenting Youth Foster Care Subject to juvenile or adult justice system Veteran Homeless or Runaway Did not complete High School At Risk YouthIf you are a male age 18 and older, are you registered with Selective Service?*YesNoNot applicableAre any members of your immediate family US Military Veterans?*YesNoPlease select any of the options below that you or a member of your household is receiving?* TANF Medicaid SNAP benefits SSI HEAP Safety NetHousehold Income*NameRelationshipSource(s) of IncomeIncome (last 6 months) Release of Information* I authorize my child's School District, CWI, The Department of Social Services, and other involved agencies to release information regarding my child with LEAP.I further authorize the E&T office to release information to the school district, CWI, DSS and other involved agencies. The information will be used to determine eligibility and appropriateness for E&T services and programs. It may also be necessary for my child to attend workshop{s} given by the E&T office to meet year-round program requirements. I understand that the E&T office may need to obtain information and school records regarding my child to comply with follow up services for at least one year. Information that may be exchanged includes, but is not limited to: Date of Birth (certificate) Address Academic Scores/Report Cards Standardized Test Scores Attendance Records Health Records CSE Classification & IEP Counseling Services Academic Intervention Svs. Psychological Math/Reading Levels Free Lunch Eligibility Food Stamp/Public Assistance Info. Employability Skills/Interests/Aptitudes I understand that all information released is confidential. I understand that information requested by the E&T office is for the purpose of determining eligibility and appropriate program services.Authorization* I certify that the information provided is true to the best of my knowledge and that there is no intent to commit fraud.I am also aware that the information that I have provided is subject to review and verification I will have to provide documentation to support this information. I am also aware that I am subject to immediate termination if I am found ineligible after enrollment and may be prosecuted for fraud and/or perjury. I understand that falsification is grounds for termination from Washington County Employment & Training programs and may result in action to recover any monies expended on my behalf or paid to me while participating in the program. Both the applicant and parent/guardian authorize the use of the participant's name and picture in any informational or promotional literature concerning the Employment & Training program participated in. (Cross off this statement if permission is not given). I have read and understand the grievance procedure on the other side of this application. I have been informed of and understand the eligibility information provided on all pages of this application. I allow release of this information for verification purposes and understand that it will be used to determine eligibility. I certify that the information provided on this application is true and correct.PhoneThis field is for validation purposes and should be left unchanged.
