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Are You Ready To Make A Difference?
Youth Entering the 6th - 9th Grade Wanted to Earn a $500 Education Award
To Participate in a Community and Environmental Service Program for the Summer!
Weld County Youth Conservation Corps Summer of Service Learn & Serve Program Personal Information Name: _________________________________________________ Last
First
Middle
Are you a United States Citizen, national, or lawful permanent resident alien:
No
Yes
Social Security Number: ________________________ Date of Birth: ___/____/______
Phone Number: __________________________
Place of Birth: __________________ Gender:
Male
Female
City/State/Country
Address: _______________________________________________ Number and Street _________________________________________________________________________ City/State/Zip
Current Grade in School: ___________
Community Service (Previous service is not a requirement) Describe how you have reached out to help others and/or how you have been involved in your own community. Elaborate on why you decided to serve or get involved, and what you received in return-that is what you learned or how it made you feel. Think in broad terms. Attach a separate sheet of paper if needed.
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
How long have you been involved in the community? If served in an organization please include the organization’s name.
_______________________________________________________________________________ _____________________________________________________ Dates of Involvement: From: _________ to _________ Hours per month:_______ Month/Year
Month/ Year
Organization Name: ____________________ Location: __________________
Description of Involvement: ____________________________________________________________________
Motivational Statement Why do you want to join the Summer of Service? What could you contribute to your project? What do you hope to gain from serving as a Learn and Serve member? If you need additional room please attach an additional piece of paper. Please limit response to 500 words or less. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Skills and Experience Listed below are skill areas that some programs find useful and may seek in applicants for Learn and Serve. Indicate the skill areas in which you have had training or experience, including volunteer or community service experience, and indicate how you gained those skills. Example:
Peer Counseling__with counselor at Brentwood Middle School___
Communications__________________
Peer Counseling _____________________
Computers/Technology_____________
Conflict Resolution ___________________
Education _______________________
Fine Arts/Crafts _____________________
First Aid ________________________
Fundraising ________________________
Leadership ______________________
Public Speaking ____________________
Recruitment _____________________
Peer Tutoring ______________________
Trade/Construction _______________
Teamwork _________________________
Youth Development ______________
Landscaping _______________________
Painting _______________________
Other (Specify) _____________________
In the space below provide additional skills and experience that may be helpful in evaluating you application. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
I certify that the information provided on this application is true and accurate to the best of my knowledge. I realize
the information is subject to review and verification and I may have to provide documents to support the information provided on this application. I also understand that I am subject to immediate termination from the program if I am found ineligible after enrollment and that I may be prosecuted for fraud and/or perjury if the information I have
provided is false. I allow the release of this information for verification purposes and understand it will be used to
determine my eligibility. I agree with the job codes assigned and I authorize the use of my Social Security Number for record keeping, payroll, and verification purposes. I am aware that I may be contacted by telephone or mail after leaving the program and asked survey questions about my employment status and earnings since leaving the
program. I am aware that my answers to these questions will remain strictly confidential and will not affect any other benefits which I may be receiving. EEO/COMPLAINT STATEMENT Employment Services of Weld County is committed to Equal Opportunity and does not discriminate in its
administration of any agency program or activity. I have been given a copy of the Equal Opportunity Statement and
have received a brief description of the complaints process. I understand that copies of the entire complaint process are available upon request.
Certification __________________________________ Applicant Signature Date
________________________________ Parent/Guardian Signature Date
Application Check List
Completed Application Copy of Birth Certificate Copy of Social Security Card E-Mail Address-If you do not have one you can make a free account at Gmail.com, Yahoo.com or Hotmail.com
Application Process All applications are due by Friday, April 29th. All applications will go through a review process and applicants will be contacted in mid May of their application status. All items from the check list must be handed in at the time of application, or the application will not be accepted. Applications may be mail to Weld County Employment Services Youth Conservation Corps, Attn: Shannon Kinahan, P.O. Box 1805, Greeley, CO 80632 or dropped off at our office at 315B North 11th Avenue, Greeley, CO.
Commitment I understand that by enrolling in the program I am entering into a 5 week commitment with the Weld County Youth Conservation Corps.
Contacts
Shannon Kinahan, (970) 353-3800 ext. 6761 Sarah Gates, (970) 353-3800 ext. 6760 Erik Warrington, (970) 353-3800 ext. 6757
Youth Entering the 6th - 9th Grade Wanted to Earn a $500 Education Award
To Participate in a Community and Environmental Service Program for the Summer!
Weld County Youth Conservation Corps Summer of Service Learn & Serve Program Personal Information Name: _________________________________________________ Last
First
Middle
Are you a United States Citizen, national, or lawful permanent resident alien:
No
Yes
Social Security Number: ________________________ Date of Birth: ___/____/______
Phone Number: __________________________
Place of Birth: __________________ Gender:
Male
Female
City/State/Country
Address: _______________________________________________ Number and Street _________________________________________________________________________ City/State/Zip
Current Grade in School: ___________
Community Service (Previous service is not a requirement) Describe how you have reached out to help others and/or how you have been involved in your own community. Elaborate on why you decided to serve or get involved, and what you received in return-that is what you learned or how it made you feel. Think in broad terms. Attach a separate sheet of paper if needed.
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
How long have you been involved in the community? If served in an organization please include the organization’s name.
_______________________________________________________________________________ _____________________________________________________ Dates of Involvement: From: _________ to _________ Hours per month:_______ Month/Year
Month/ Year
Organization Name: ____________________ Location: __________________
Description of Involvement: ____________________________________________________________________
Motivational Statement Why do you want to join the Summer of Service? What could you contribute to your project? What do you hope to gain from serving as a Learn and Serve member? If you need additional room please attach an additional piece of paper. Please limit response to 500 words or less. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Skills and Experience Listed below are skill areas that some programs find useful and may seek in applicants for Learn and Serve. Indicate the skill areas in which you have had training or experience, including volunteer or community service experience, and indicate how you gained those skills. Example:
Peer Counseling__with counselor at Brentwood Middle School___
Communications__________________
Peer Counseling _____________________
Computers/Technology_____________
Conflict Resolution ___________________
Education _______________________
Fine Arts/Crafts _____________________
First Aid ________________________
Fundraising ________________________
Leadership ______________________
Public Speaking ____________________
Recruitment _____________________
Peer Tutoring ______________________
Trade/Construction _______________
Teamwork _________________________
Youth Development ______________
Landscaping _______________________
Painting _______________________
Other (Specify) _____________________
In the space below provide additional skills and experience that may be helpful in evaluating you application. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
I certify that the information provided on this application is true and accurate to the best of my knowledge. I realize
the information is subject to review and verification and I may have to provide documents to support the information provided on this application. I also understand that I am subject to immediate termination from the program if I am found ineligible after enrollment and that I may be prosecuted for fraud and/or perjury if the information I have
provided is false. I allow the release of this information for verification purposes and understand it will be used to
determine my eligibility. I agree with the job codes assigned and I authorize the use of my Social Security Number for record keeping, payroll, and verification purposes. I am aware that I may be contacted by telephone or mail after leaving the program and asked survey questions about my employment status and earnings since leaving the
program. I am aware that my answers to these questions will remain strictly confidential and will not affect any other benefits which I may be receiving. EEO/COMPLAINT STATEMENT Employment Services of Weld County is committed to Equal Opportunity and does not discriminate in its
administration of any agency program or activity. I have been given a copy of the Equal Opportunity Statement and
have received a brief description of the complaints process. I understand that copies of the entire complaint process are available upon request.
Certification __________________________________ Applicant Signature Date
________________________________ Parent/Guardian Signature Date
Application Check List
Completed Application Copy of Birth Certificate Copy of Social Security Card E-Mail Address-If you do not have one you can make a free account at Gmail.com, Yahoo.com or Hotmail.com
Application Process All applications are due by Friday, April 29th. All applications will go through a review process and applicants will be contacted in mid May of their application status. All items from the check list must be handed in at the time of application, or the application will not be accepted. Applications may be mail to Weld County Employment Services Youth Conservation Corps, Attn: Shannon Kinahan, P.O. Box 1805, Greeley, CO 80632 or dropped off at our office at 315B North 11th Avenue, Greeley, CO.
Commitment I understand that by enrolling in the program I am entering into a 5 week commitment with the Weld County Youth Conservation Corps.
Contacts
Shannon Kinahan, (970) 353-3800 ext. 6761 Sarah Gates, (970) 353-3800 ext. 6760 Erik Warrington, (970) 353-3800 ext. 6757
