Docstoc

syep

Document Sample
syep Powered By Docstoc
					LIVINGSTON COUNTY
OFFICE OF WORKFORCE DEVELOPMENT
Livingston County Government Center 6 Court Street, Room 105 Geneseo, NY 14454-1043
Keith Mitchell, Director ckmitchell@co.livingston.ny.us Phone: (585) 243-7047 Fax: (585) 243-7598

February 4, 2009 Dear Youth and Family: Attached is an application packet for the Livingston County Summer Youth Employment Program (SYEP). SYEP is a work experience program for Livingston County Youth age 14 to 24. Youth are assigned to a work site or a career exploration program and are paid minimum wage for work and training time. Youth must meet income and eligibility guidelines in order to participate in the program. This packet contains: • • • • • Program Eligibility Guidelines and List of Documents Required for Eligibility (back) Youth Program Application Form Agency Release of Information and Photo Release Form Medical Information and Emergency Release Form NYS Employees’ Retirement System Option Form

Applications will be accepted ongoing through May 31. However, placements may be made on a first come basis so it is important to get applications in as soon as possible. Copies of documentation may be sent with the application. Please send completed forms to the address listed below: Summer Youth Employment Program Livingston County Office of Workforce Development 6 Court Street, Room 105 Geneseo, NY 14454 A letter with an appointment time for an eligibility interview will be sent to the youth applicants in late April. These interviews are scheduled in early to mid May and located in Geneseo, Dansville, Avon and Nunda. All of the required documentation will need to be submitted or copied before or at that interview. Feel free to contact the office at 243-7047 or by emailing nhawkins@co.livingston.ny.us if you have any questions. Sincerely,

Keith Mitchell Director

C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\SYEP Family cover ltr stimulus.doc

Livingston County Summer Youth Employment Program (SYEP) And WIA Year Round Youth Services Program Eligibility Guidelines for 2009 SYEP and WIA Youth Services are open to Livingston County residents, age 14-21, who are determined to be income eligible. Youth may be eligible for the SYEP by TANF or WIA income guidelines. Youth are eligible for the Year Round Program only under WIA guidelines. FAMILY is defined as individuals who are related by blood, marriage or adoption and reside in the same household. 1. TANF Summer Youth Employment Program (SYEP) Eligibility is based on income only. Youth eligible under TANF are not required to have an employment barrier or disability. Cash assistance, Medicaid and food stamp recipients are categorically eligible.
2008 (to be updated later in 2009) TANF Income (200% FPL) Guidelines Family Size…………Annual Family Income 1……………………………$20,800 2……………………………$28,000 3……………………………$35,200 4……………………………$42,400 5……………………………$49,600 6……………………………$56,800

2. WIA SYEP and Year Round Services Eligibility Youth eligible under WIA must be income eligible and present at least one barrier to employment. This program is presently focused on youth 16 and up. The following are WIA barriers to employment: • School drop-out • Homeless, runaway, or foster child • Pregnant or parenting youth • Offender - any involvement with the juvenile justice system including PINS • Deficient in Basic Literacy Skills - Functioning at or below an 8th grade reading comprehension and/or math computation level, or functioning 2 grade levels below age appropriate level • Additional assistance needed to complete an educational program or to secure and hold employment. If a youth has an IEP or 504, it is assumed they need additional assistance but youth without the IEP or 504 may be determined to need assistance. A youth with a disability, may be considered a Family of One for the purposes of family income. The WIA definition of a “person with a disability” is: any person who has a physical or mental disability that constitutes or results in a substantial handicap to employment that results in a significant diminishment of occupational choices. Documentation of this “disability’ is a form or letter signed by a doctor, CSE chair, school psychologist, etc.
2008 (to be updated later in 2009) WIA Income Guidelines Family Size…………Annual Family Income 1……………………………$10,400 2……………………………$14,000 3……………………………$17,600 4……………………………$21,200 5……………………………$24,800 6……………………………$28,400

C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\~3062469.doc

Livingston County Office of Workforce Development Summer Youth Employment (SYEP) and WIA Year Round Program List of Documents Required for Eligibility The following information and documents are required in order to determine eligibility. Please start gathering these now. Copies of documents may be sent in with the application. Any documents not sent will be required at the time of the eligibility interview. Applicants will receive a letter with an interview time and place by the end of April. If under 18, a parent must attend the interview. Questions? Call 243-7047. • • Application Packet with Release Forms with all appropriate signatures ° Medical Release Form ° Information Release Form Income ° Categorically Eligible if receiving cash assistance, food stamps or Medicaid Social Services award letter, Benefit or Medicaid Card ° Proof of ALL Family Income for the past 26 Weeks (6 Months) • Proof of reduced and free lunch eligibility (from school) • Most recent paycheck stub(s) • Copy of Social Security check, award letter, or bank statement • Retirement income statement, check, or bank statement • Unemployment Insurance - Determination Letter or payment history print out from internet • Copy of Child Support and/or Alimony Check, signed note from parent paying stating the total amount or form from Support Collection Unit • Statement of Self-Employment income showing income and expenses Proof of Age – One of the following ° Birth Certificate ° Driver’s License or Learner’s Permit ° Work Permit may also be used if above not available Proof of United States Citizenship – One of the following ° Birth Certificate ° Passport ° Public Assistance/Food Stamp records Social Security Card Actual Work Permit (if applicant is under 18) – The work permit is kept on file with the Workforce Department for the duration of the program as Livingston County is the employer of the minor. Retirement Option Form with appropriate signatures (SYEP ONLY)

•

•

• •

•

Return all forms to: SYEP and Youth Services Programs Livingston County Office of Workforce Development 6 Court St, Room 105, Geneseo, NY 14454
C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\documents required list.doc

LIVINGSTON COUNTY OFFICE OF WORKFORCE DEVELOPMENT SYEP and YEAR ROUND YOUTH

PROGRAM APPLICATION

GENERAL INFORMATION: Social Security # __ __ __ - __ __ - __ __ __ __ Last Name _________________________________________________

DATE: _______________________________ Date of Birth ________/________/_________ First Name _____________________________ M.I. _________

Street Address _______________________________________________________________________________________________________ Mailing Address ______________________________________________________________________________________________________ City ______________________________ Phone (__ __ __) __ __ __ - __ __ __ __ Sex: Male __________ Are you a US Citizen? Yes Ethnicity Female_________ State ________ Zip Code ________ County ____________________________________ Message Phone: (__ __ __) __ __ __ - __ __ __ __

Cell Phone (__ __ __) __ __ __ - __ __ __ __

E-mail Address: ____________________________________________________________ _______ No_______

_______ No _______ If not, are you authorized to work in the United States Yes Black or African American Asian (not Hispanic)

Explain, please ______________________________________________________________________________________________________ White (not Hispanic) Alaskan/American Indian Hispanic or Latino Hawaiian/Pacific Islander Other

Note: Ethnicity question is voluntary. Information will be kept confidential and is intended for use solely in connection with record keeping and affirmative action requirements. You will not be penalized for refusal to answer. EDUCATION: If currently enrolled in school, please circle your grade level:

7

8

9

10

11

12

What school district are you (or were you) attending? __________________________________________________________________ If not presently in school, did you ….. Drop out of High School: Yes ______ No _______ In what grade? __________ In what year? _____________ Receive a High School Diploma or GED? Yes ______ No _______ Receive an IEP Diploma? Yes ______ No _______ Attend Vocational School? Yes ______ No _______ Attend College/Are you currently in College? Yes ______ No _______

ADDITIONAL INFORMATION (please complete as this information assists in the eligibility process) : Do you have any of the following: Physical Disability _____ IEP _____ Learning Disability _____ Developmental Disability _____ 504_____ Emotional Disability _____ Are you pregnant? Yes _____ No _____ Are you a parent? Yes _____ No _____ Are you in foster care? Yes _____ No _____ Have you ever been involved with the Juvenile Justice System or Probation (including PINS) or convicted of any crime except for minor traffic violations? Yes _____ No_____ If yes, who is your probation officer? ___________________________________________________________ Do you have a driver’s license? Yes _____ No _____ If No, do you have a Learner’s Permit? Yes _____ No _____ What is your mode of transportation to a job or appointment? Bicycle _____ Parents _____ Own Car _____ Public Transportation _____ If under 18 years of age, do you have a Work Permit? Yes _____ No _____ **If No, you MUST have a valid Work Permit to participate in the Work Experience portion of the Program** If over 18 years of age, are you registered for the Selective Service? Yes _____ No _____ **If No, you MUST be registered for the Selective Service in order to participate
C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\Youth Application Form.doc

INCOME INFORMATION FOR ELIGIBILITY: Can you be claimed as a dependent on any income tax forms? Yes _____ No _____ Please list all people living in the household who are related to the applicant by blood, marriage, or adoption, their age, relationship to the applicant, and their gross earnings, if any, from the previous 9 months PLEASE INCLUDE YOURSELF ON THE FIRST LINE!!!. Documentation of the income may be sent with this application or must be provided at the eligibility interview. Name _______________________________________ Age _____ Relationship ____SELF_________ Earnings $ ____________ per wk Name _______________________________________ Age _____ Relationship _________________ Earnings $ ____________ per wk Name _______________________________________ Age _____ Relationship _________________ Earnings $ ____________ per wk Name _______________________________________ Age _____ Relationship _________________ Earnings $ ____________ per wk Name _______________________________________ Age _____ Relationship _________________ Earnings $ ___________ per wk Name _______________________________________ Age _____ Relationship _________________ Earnings $ ___________ per wk Are you or any family member presently receiving (Check all that apply and indicate the amount received monthly): Cash Welfare Assistance? $ _______________________ per month Food Stamps or other income support? $ _____________ per month Social Security Retirement Benefits $ ________________ per month Social Security or Private Disability $ ________________ per month Supplemental Security Income (SSI) $ _______________ per month VA Retirement Pension $ __________________________ per month Death Benefits $ _________________________________ per month Alimony $ _____________________________________ per month Child Support $ __________________________________ per month Rental Income $ _________________________________ per month Unemployment Benefits $ _________________________ per month Lifetime Workers Compensation $ ___________________ per month Private Retirement Pensions $ ______________________ per month Fixed Term Compensation $ _______________________ per month

CERTIFICATION: I/We certify that the information provided in this application packet is true to the best of my/our knowledge. I/We understand this information is used to determine eligibility and I/we may be required to document the accuracy of this information. This information is subject to external verification and may be released for such purposes. If found ineligible after enrollment, I/we understand the applicant will be terminated from the program. If I am terminated as a result of falsifying information on this application, I/we understand I/we may also be prosecuted for fraud. My/Our signature serves as giving my/our permission to verify any and all information contained in this application and attached forms in the application packet. I/We acknowledge that I may be asked to provide follow-up information to assist in evaluation of this program. Applicant Signature ________________________________________________________________ Parent/Guardian Signature __________________________________________________________
**Required if applicant is under the age of 18

Date ___________________________ Date ___________________________

C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\Youth Application Form.doc

WORK HISTORY:
Have you participated in the Livingston County Summer Youth Employment Program before? YES _______ NO_______

If so, when? _______________

And at what worksite? _____________________________________________________

List all employers and work history below: Job Title ______________________________________________ Employer _________________________________________________ Wage $__________________

Address _________________________________________________________________________________ City _________________________________________________________ Start Date _____/_____/_____ End Date _____/_____/_____ State ________

Country, if not US ______________________

Reason for leaving _____________________________________

Job Duties __________________________________________________________________________________________________________

Job Title ______________________________________________

Employer ________________________________________________ Wage $__________________

Address _________________________________________________________________________________ City _________________________________________________________ Start Date _____/_____/_____ End Date _____/_____/_____ State ________

Country, if not US ______________________

Reason for leaving _____________________________________

Job Duties __________________________________________________________________________________________________________

Job Title ______________________________________________

Employer ________________________________________________ Wage $__________________

Address _________________________________________________________________________________ City _________________________________________________________ Start Date _____/_____/_____ End Date _____/_____/_____ State ________

Country, if not US ______________________

Reason for leaving _____________________________________

Job Duties __________________________________________________________________________________________________________ GOALS: What steps do you need to take to increase your opportunities of getting a job?____________________________________________________ ___________________________________________________________________________________________________________________ If you could have any job right now, what job would you want? ___________________________________________________________________________________________________________________ What job do you want 5 years from now? _________________________________________________________________________________ Why? _____________________________________________________________________________________________________________
C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\Youth Application Form.doc

SKILLS and INTERESTS:

•

List skills and abilities that you used in your jobs, for example, construction skills, or skills and abilities that you have learned, for example the ability to type or fix motors. List any and all computer and technology skills.

__________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ • • Do you speak any languages other than English? YES _______ List any honors you have received or activities you participate in:
NO ________ What language? ________________________________

________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ • What hobbies do you have?

________________________________________________________________________________________________________________

•

What do you do in your spare time? Walk/jog
Make craft projects Work on cars/bikes Read

Talk with friends Play video games Cook/bake Construct models, projects

Baby-sit Play Sports Participate in youth groups Other _________________________

•

Would you like to work in any of these settings? Office Park Maintenance Cafeteria School Recreation Program Bus Garage Center for Disabled Adults/Youth Nursing Home Day Care Center Hospital Other _________________________

•

Do you prefer? I prefer to work with people. I prefer to work with the elderly. I prefer to work with children. I prefer to work with individuals with disabilities. I prefer to work by myself. I prefer to work with a group. I prefer to work indoors. I prefer to work outdoors.

C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\Youth Application Form.doc

LIVINGSTON COUNTY OFFICE OF WORKFORCE DEVELOPMENT
Livingston County Government Center 6 Court Street, Room 105 Geneseo, NY 14454-1043
Phone: (585) 243-7047 Fax: (585) 243-7598

SYEP and YEAR ROUND YOUTH SERVICES PROGRAM Agency Release of Information Form
I/we hereby authorize the release of information to or by the Livingston County Office of Workforce Development with the agencies listed below in order to determine eligibility and to provide complete and proper Case Management Services. I/we understand that the release will allow communication at needed intervals. I/we understand that this release will be updated annually and may be revoked by me at any time with written notification. Also, I/we understand that I/we may cross out any agency that I/we do not wish the Office of Workforce Development to share information with.

__________________________________________________________________________
Youth’s Name (Please Print) _______________________________________________________ Youth’s Signature _______________________________________________________ Parent/Guardian Signature (If youth is under 18) _______________________ Date _______________________ Date

AGENCIES
• • • • • • • • Youth’s School District Livingston County Mental Health Livingston County Probation Livingston County Youth Advocacy NYS Department of Labor Livingston County Dept of Social Services Livingston County Dept of Health and TASA Council on Alcohol & Substance Abuse Liv. Co. • • • • • • • • Genesee Valley BOCES Mobile Mental Health Team Livingston County Sheriff’s Office & Jail Livingston County Youth Bureau Catholic Charities of Livingston County Youth’s Worksite Supervisor NYS One Stop Operating System Database ___________________________________

Photo Release
I give permission for my photo to be taken at work experience, field trips, workshops or in other activities sponsored by the Livingston County Office of Workforce Development as part of the Summer Youth Employment Program or Year Round Youth Program. These photos may be published in the newspaper, posted or used in reports and publications of the department or of the GLOW Workforce Investment Board.

_______________________________________________________ Youth’s Signature _______________________________________________________ Parent/Guardian Signature (If youth is under 18)

_______________________ Date _______________________ Date

C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\Agency Release.doc

Livingston County Office of Workforce Development Medical Information and Emergency Release Form Youth Name: ____________________________________________________________ I give permission for my child to be treated for illness/injury sustained in connection with their participation as a Youth Employee for Livingston County Office of Workforce Development. I also give permission for my child to be transported by a counselor, worksite supervisor, Workforce Development staff member, or ambulance in the event of an emergency. The above named participant: _____is NOT currently covered by health insurance. _____is covered by MEDICAID. Medicaid #_______________________________ _____is currently covered under ________________________________________ (Insurance Name and Contact #) Does the participant have any health conditions? _____YES _____NO If YES, please describe _______________________________________________ Is the participant taking any medication? _____YES _____NO If YES, please describe _______________________________________________ If YES, is the participant bringing this medication to the program? _____YES _____NO If YES, is the participant responsible for taking this medication? _____YES _____NO If there is any other medical information about your child that you feel we should be aware, describe here ________________________________________________________________________ In the event an illness or emergency should occur, contact: _________________________ Mother/Guardian Name _________________________ Home Phone _________________________ Business Phone _________________________ Cell Phone __________________________ Father/Guardian Name __________________________ Home Phone __________________________ Business Phone __________________________ Cell Phone

If a parent/guardian is unable to be reached, contact: _________________________ Name & Relationship _________________________ Home Phone _________________________ Business Phone _________________________ Cell Phone __________________________ Name & Relationship __________________________ Home Phone __________________________ Business Phone __________________________ Cell Phone

Parent/Guardian Signature __________________________________Date____________ Applicant Signature _______________________________________Date ____________
C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\Medical Release Form.doc

NOTICE OF NYS EMPLOYEES’ RETIREMENT SYSTEM OPTION FOR ALL TEMPORARY EMPLOYEES

In accordance with Chapter 878 of the Laws of 1986, you are hereby notified that you have the option to join the NYS Employees’ Retirement System. If you decide to become a member, you must complete the application. I fully understand that once I join the system, I will be required to make contributions from my paycheck as long as I continue to work for the County of Livingston, and cannot withdraw my membership. (If you were in the SYEP program or work experience last year and joined the system you must re-enroll in the system. You should have received a NYS Retirement Enrollment #. ) I hereby acknowledge that I have read this Notice of NYS EMPLOYEES’ RETIREMENT SYSTEM OPTION.

__________________________ Date

___________________________ _____ Participant’s Signature ________________________________ Parent Signature (if participant is under the age of18)

RETIREMENT OPTION FORM I WISH to join the NYS Employees’ Retirement System. (A separate form entitled Article 15 Membership Registration Form will be provided to you and must be signed in front of a notary.)

I DO NOT WISH to join the NYS Employees’ Retirement System. I understand that even though I DO NOT join the Retirement System I will have social security coverage as mandated by the Omnibus Reconciliation Act of 1990 effective July 2, 1991.

__________________________ Date

________________________________ Participant’s Signature

________________________________ Parent Signature (if participant is under the age of18)

C:\DOCUME~1\tqt\LOCALS~1\Temp\notes6030C8\Retirement Option Form.doc


				
DOCUMENT INFO