Special Initiative – Application Package Cover Sheet

Special Initiative – Application Package Cover Sheet

Referring Agency:

Participant Name:

Select Applicant Barrier to employment and attach Agency letter: Foster Care Offender/Justice Involved Homeless / Runaway ACS Preventative Services

Please select the SYEP Provider this application will be submitted to: C.C.M.S - Community Counseling & Mediation St. Nicks Alliance Corp. Center for Alternative Sentencing and Employment Services The Children’s Aid Society Henry Street Settlement, Inc. United Activities Unlimited, Inc. La Guardia Community College- Research Foundation Wildcat Service Corporation Samuel Field YM & YWHA

Please list three (3) points of contact at your agency or individual case managers in the event there is a concern with the applicant: (List in the order of choice)

Name: Title:

Phone #: Email:

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Name: Title:

Phone #: Email:

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Name: Title:

Phone #: Email:

Are you aware of any issues that would prevent this applicant from being successful at the following sites?

Childcare Retail Other: Please explain below

Would you recommend that this participant be placed at the following types of sites?

Sheltered Internship or In-house Service Learning Project (requires additional guidance) No restrictions, capable of independently following directions with little guidance Other: Please explain:

Notes: Referral Agency Signature:

Date:

Provider Print Name: Provider Signature upon acceptance of package:

Date Rec’d:

Please track all applications submitted and accepted by the provider. Only one (1) application can be submitted per applicant. Submission of an application package is contingent upon the availability of slots with the provider and does not guarantee enrollment.

Name_________________________________________________________ SYEP ID# _____________________

Participant Enrollment Survey (PES) 2019 Older Youth

One application will be accepted for each applicant. Completed applications will be entered into a lottery to determine those applicants who will be offered a position in the Summer Youth Employment Program. SUBMISSION OF AN APPLICATION DOES NOT GUARANTEE ELIGIBILITY OR ENROLLMENT INTO THE PROGRAM. The following application items: Spoken Language, Disability Status is voluntary and will be treated with confidentiality. They cannot be used to affect your status in receiving employment, benefits and/or services. Information provided may be used by the City of New York to improve City services or to access additional funding.

1. Social Security Number (Please be accurate)

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2. Last Name 3. First Name 4. MI

5. Birth Date (MM/DD/YYYY) 6. Gender (Check one) 7. Citizenship Status (Check one)

/ / Male Female U.S. Citizen Permanent Resident Alien

Other

8. Selective Service Registration # & Date- Males 18 years of age must be registered with the Selective Service System to participate in the program (if you have not already registered; visit www.sss.gov .)

9.

Alien Number:

# - - Date / / USCIS Form #:

10. Street Address (Number and Street) 11. Apt. 12. Zip Code

13. Do you live in a NYCHA Housing Development?

No

If No; Go to question 14.

Yes If Yes, Name the Development:

14. Borough (Check One) Bronx Brooklyn Manhattan Queens Staten Island

15. Applicant’s Ethnicity (Select One) Hispanic or Latino Not Hispanic or Latino

16. Applicant Race (Select One) Black or African American American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Asian White or Caucasian Other

17. Other than English, what Albanian Arabic Bengali Chinese (incl. Cantonese & Mandarin) French

Language are you most Fulani German Greek Gujarati Haitian Creole Comfortable speaking? Hebrew Hindi Hungarian Italian Japanese (Check all that apply) Korean Kru, Ibo or Yoruba Mande Punjabi Persian Polish Portuguese Romanian Russian Spanish Tagalog Turkish Urdu Vietnamese Yiddish Other (Describe): _________________

18.

Applicant’s Home Phone #

19.

Applicant’s Cell Phone #

20.

Applicant’s Email

-

-

-

-

21. Name of Parent or Legal Guardian (Last Name)

22. First Name

23. Emergency Contact Phone #

-

-

Educational Status 24. Education – Student Type Currently Attending School Not in-school 25. Current Educational Status J.H.S grade 6th 7th 8th H.S. grade 9th 10th 11th 12th College Freshman Junior Sophomore Senior 26. Please indicate the school system you attend DOE CUNY Other a. What school did/do you attend? b. Indicate last grade completed.

Grade 0 - 8 High School Graduate/ HSE Grade 9-11 12+ Some Post-Secondary 2 or 4 year College Graduate

Income & Other Information

27. Total family income (gross) for the last SIX months $

28. Number of family members currently living in applicant’s household

a. Type of Applicant Household

Single Parent Female

Two Adults-No Children

Single Person – No Children

Single Parent Male

Two Parent Home Other

29.

Is applicant or applicant’s family currently receiving public assistance? Yes No (Skip to #31)

30. Type of Public Assistance (Check all that apply)

Family Assistance (formerly known as AFDC)

S.S.I.

Supplemental Nutrition Assistance Program (SNAP)

Safety Net/Home Relief

Other _____________________

31. Is the applicant any of the following (Check all that apply) Disabled Offender/Justice Involved Served in the Military Foster Care ACS Preventative Services Does Not Apply

Homeless/Runaway Parent

http://www.sss.gov/

Name_________________________________________________________ SYEP ID# _____________________


Review NY State Eligibility Status on Next Page.

NY STATE Eligibility Status A comparison of the information provided in your application with the NYS 200% poverty standards guideline has been completed to certify your eligibility for NY STATE Services. Based on those findings: The applicant is certified for NY STATE Services. (Please initial below in the participant and the Parent /Legal Guardian)

By initialing this, I am swearing, under penalty of perjury, that all of the enclosed information is true to the best of my knowledge and that I am willing to cooperate with any efforts to verify the information provided.

Participant Initials

Parent/Guardian Initials

33. Favorite Subject: Least Favorite Subject:

34. What is your current grade average? 34a. What is your major (potential) in college?

35. If educated outside of the U.S., comparable grade level:

Employment History & Goals

36. Work History: (Give a brief overview of the types of jobs you have held in the past.)

37. Has participant made informed job choices in the past? Yes No

38. Does participant possess appropriate labor market information? Yes No

39. List three work related skills you possess:

a. b. c.

40. What career interests has the participant expressed? (Check all appropriate categories.)

Creative Arts Mechanical Financial Science

Industrial Human Services Medical Business Administration

Food Services Protective Services Athletics Law

Retail Technology Education Skilled Trades

Other (Specify):

41. What is the applicant’s long term career goal?

42. Have you set a savings goal for the summer? Yes (Go to a.) No Don’t Know Does not want to disclose

a. How much of your salary do you plan to save this summer? $

Health Questionnaire (THIS SECTION MUST BE COMPLETED AND SIGNED BY PARTICIPANT AND PARENT/GUARDIAN.)

43. Do you have any allergies, e.g. asthma, hay fever, penicillin, dust, etc.? Yes (please list) No

44. Are you presently taking any medication? Yes (please list) No

45. Do you have any illness, injury or on-going medical condition which would prevent you from performing specific tasks at the Worksite?

Yes (please explain)

No

32. School History: (Ask the participant to discuss the schools they have attended in the past and why they left.

SCHOOL(S) ATTENDED FROM TO REASON FOR LEAVING COMMENTS (Note if Alternative School)

Name_________________________________________________________ SYEP ID# _____________________


Maximum Hours & Unpaid Orientation Acknowledgment Youth enrolled in subsidized jobs may participate in Summer Youth Employment Program activities a maximum of 25 hours per week in the case of older youth (aged 16-24). Youth in unsubsidized jobs are not subject to an hourly limit pursuant to SYEP, but may be subject to an hourly limit by their worksite. The hourly limit includes both educational and employment activities in the case of younger youth. The participant’s weekly activity hours must not exceed the applicable limit. Additionally, youth enrolled in subsidized jobs must complete an unpaid orientation prior to beginning employment activities. Participant completion of the unpaid orientation is a prerequisite for engaging in employment activities. By initialing this section the participant and the parent fully understand that participation in SYEP activities, and payment for those activities, is limited to the applicable maximum number of hours per week; the participant and the parent also understand that the participant must complete an eight-hour, unpaid orientation prior to engaging in employment activities.



Participant Pay Card Acknowledgment I acknowledge that I have a choice of payment methods for my payroll. I may choose to be paid by debit card issued by MetaBank at 5501 South Broadband Lane, Sioux Falls, SD 57108 or direct deposit into an existing bank account. I understand that I may make my selection in accordance with the enrollment procedures set forth for the Summer Youth Employment Program. If I do not complete a selection of payment method by the due date disclosed within the enrollment procedures, I understand that I shall be paid by debit card and agree to be so paid. By initialing this section the participant and the parent agree they acknowledge the terms stated above as it pertains to their payment options.



Photo/Video Release Wavier I hereby authorize and permit the City of New York Department of Youth and Community Development (“DYCD”) or its authorized agent, without compensation therefore, permission to photograph, publish, reproduce, record and use, with or without my name or the name of the person for whom I am the parent/guardian. This includes, but is not limited to, photographs, quotes and/or text, motion pictures, videotapes, Web site pages and personal stories or audio tapes of and/or by me or the person for whom I am the parent/guardian.

I release DYCD from any and all legal liability that may arise from the release of information requested. I agree that all text, Web information/hypertext, photographs, motion pictures, negatives, prints and transparencies, videotapes and audio tapes made of and/ or by me or the person for whom I am the parent/guardian by or for DYCD, shall be the exclusive property of DYCD, which in its sole discretion may use this material as it sees fit in any medium or forum. By initialing this section the participant and the parent agree to the Photo/Video terms stated above. If they choose not to participate; please mark this box N/A.



CERTIFICATION STATEMENT I, the undersigned, certify that all information on this form is true and correct. I understand that my statements are subject to verification. I further understand that any false statements may subject me to criminal prosecution under both New York State Penal Laws, section 175.35 and Federal Law, 18 U.S.C.A. 1001, and to civil action for return of all monies received. I agree and accept that I will abide by all applicable rules and regulations of this program.

Thank you for your participation and Good Luck in the Summer Youth Employment Program.

Consent for Emergency Medical Treatment

I, _______________________________________, the parent/guardian of ___________________________________ do hereby give authorization to the staff of, the SYEP Provider, or the Worksite supervisor to obtain emergency medical treatment for my child if s/he is injured or requires medical attention in my absence with the understanding that the family will be notified as soon as possible.

Participant Signature Date Parent/Guardian Signature Date

Participant Signature Date Intake Officer Signature Date

Parental/Guardian signature is required for all applicants if/when the applicant inputs the parent/guardian’s income to apply and provides parent/guardian’s income documents to enroll/participate in the Summer Youth Employment Program. [Question #27 above]

Parent/Guardian Signature Date

If you are selected from the lottery or recruited for a summer opportunity, you will need to bring certain documents to your SYEPprovider. You must submit COPIES of one (1) item from categories 1-8 listed below as it applies to you. These items are needed toofficially complete your enrollment so that you are eligible for SYEP. Note that some documents may satisfy more than onecategory (e.g. U.S. Birth Certificate or current U.S. Passport for categories 2 and 7).

1. Proof of Identity

Official Picture ID(school, city, state, government issued)IDNYC Municipal ID will be accepted

2. Proof of Age

Birth Certificate OR Benefit Card OR NYS Driver/Non-Driver’s License OR Alien Registration Card OR Valid U.S. Passport

3. Proof of Social Security Number

Social Security Card (ONLY)

4. Proof of Address (Dated within the last 6 months)

Home Utility Bill OR Current Lease, Mortgage, Deed OR Current Cable Bill (Must have Phone ServiceListed) OR Official Mail from a Federal, State or City Agency

5.SYEP Application

A signed SYEP application is required for allyouth. Youth under the age of 18 are required tohave the signature of a parent or guardian.

6. Proof of Employment Authorization

Report Card (dated within the last 6 mos ) OR Official School Transcript OR NYS Driver/Non-Driver’s License OR Voter’s Registration Card OR U.S. Military Card /Draft Record OR

7. Proof of Citizenship/Alien Status

Valid U.S. Passport OR U.S. Birth Certificate OR Alien Registration Card OR I-94 , I-551, I-797 OR Certificate of Naturalization OR Employment Registration Card

Please note: all references to the word current meandocuments dated within the last six (6) months orwhere applicable, documents which are still validand have not expired. The status of your applicationcan be found at www.nyc.gov/dycd.

Summer Youth Employment Program (SYEP)

Required Document Checklist:

OLDER YOUTH(16-24 Years Old)

Reminder: ONLY COPIES OF THESE DOCUMENTS WILL BE ACCEPTED

8. Working Papers (Must be age applicable)

Working papers can be acquired through yourschool. If you are not attending school, call 311 orcontact your local District Office. Required for Youth under 18 years of age ONLY

16 and 17 years of age: Green Card

9. Please provide ONLY if applicable

Selective Service Registration Card ORSelective Service “Online Receipt”Required for males 18 years of age or older

Proof of Disability: Official documentation asapplicable certifying disability from a physician,ACS, HRA, School, Social Service agency orauthorized entity.

AGENCY LETTERHEAD

Date: __________________

Applicant Name: __________________________________________ Applicant DOB: _______________ Applicant Address: _________________________________________ _________________________________________ This letter certifies that (Applicant Name, DOB) is applying to the 2019 Summer Youth Employment Program (SYEP). The applicant is (please insert relevant agency language i.e. in the care and custody of Agency Name). This letter will serve as verification of the applicant’s eligibility for the Special Initiative service option of SYEP. If you have any questions, please feel free to contact me at the information below. Sincerely, ____________________________________________ Case Worker Name Phone Number Email Address _____________________________________________ Agency Point Person Phone Number Email Address

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

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Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Summer Youth Employment Program 2019 Vulnerable Youth Providers

Provider First Name Last Name Title Phone Ext Cell Phone

Number Email Address

C.C.M.S. aka Community Counseling & Mediation Naphtali Aiken Program Director 718-230-5100 122 917-304-6333 [email protected]

Center for Alternative Sentencing Employment Services, Inc. Maceo June

Director of Education & Career Services, Harlem 212-553-6621

646-946-1898 [email protected]

Henry Street Settlement Johanna Ramirez Program Diretcor 212-254-3100 3221 347-922-3426 [email protected]

Research Foundation of CUNY on behalf of La Guardia Community College Adjoa Gzifa Director 718-482-5347


Samuel Field YM & YWHA, INC. aka Central Queens Y Danielle DeAngelis

Senior Director, Youth Employment Programs 718-268-5011 164 631-681-7202 [email protected]

St. Nicks Alliance Corp. Folasade Maddux

Youth Employment Director 718-599-9224 36 646-420-1113 [email protected]

The Children's Aid Society Sandino Sanchez Director 917-286-1535


United Activities Unlimited Inc Tatiana Arguello Program Director 718-689-4899


United Activities Unlimited Inc Brian Licata

Deputy Director of Workforce Development 718-702-5692


Wildcat Service Corporation Aron Myers

Director of Youth & Young Adult Programs 212-727-4291 914-803-6826 [email protected]

mailto:[email protected]



