Summer Youth Intern Program 2017
Application for Boley Centers, Inc.
Summer Youth Intern Program 2017 COMPLETION OF THIS APPLICATION
DOES NOT GUARANTEE A POSITION
YOU MUST BE AT LEAST 16 YEARS OLD AND NOT OLDER THAN 21 YEARS OF AGE, AS OF APRIL 22,2017. THE TOTAL ANNUAL HOUSEHOLD INCOME WILL BE USED TO DETERMINE ELIGIBILITY.
INCOMPLETE APPLICATIONS
WILL BE DISCARDED.
NO PHOTOCOPIES
WILL BE ACCEPTED.
PLEASE PRINT IN INK: NAME
SSN(ENTIRENUMBER)
___
HOMEADDRESS
__ CITY
HOME PHONE ('--__ ----" EMAILADDRESS: AGE
STATE
ZIP CODE
EMERGENCY/OTHER PHONE ~
_ _
BIRTH DATE
MALE
_
DO YOU HAVE A DRIVER'S LICENSE, LEARNER PERMIT, OR STATE I.D.?
YES
FEMALE
_
NO (MANDATORY REQUIREMENT)
or
DO YOU HAVE A BANK ACCOUNT? YES OR NO (MANDATORY FOR DIRECT DEPOSIT) ARE YOU IN HIGH SCHOOL OR COLLEGE? YES
or
NO IF NO, HIGHEST GRADE COMPLETED?
IF YES, NAME OF SCHOOL OR COLLEGE
CREDITS
PLEASE SELECT EDUCATIONAL CERTIFICATION RECEIVED: MICROSOFT
D HIGH
SCHODL DIPLOMA
------------------
MAJOR INTERNET
__ CAD/CAT
_
D SPECIAL DIPLOMA DCERT. OF COMPLETION DGED D NONE
WHAT TYPE OF JOB ARE YOU INTERESTED? 1.
_
2.
--------------------
RACE (Please select one):
D
WHITE/CAUCASIAN
D
D
NATIVE AMERICAN
DASIAN AMERICAN
D HISPANIC/NON-WHITE
BLACK/AFRICAN AMERICAN D
OTHER
_
ETHNICITY (Please select one): 0 PUERTO RICAN 0 MEXICAN 0 CUBAN 0 OTHER HISPANIC
o HAITIAN 0 INONE OF THE ABOVE THE FOLLOWING INFORMATION WILL HELP US DETERMINE YOUR ELIGIBILITY FOR THE SUMMER PROGRAM: 1. 2. 3. 4. 5. 6. 7. 8. ~.
HAVE YOU EVER HAD A JOB? Yes HAVE YOU EVER BEEN ARRESTED/PENDING CHARGES? (Background checks mandatory) Yes IS YOUR HOUSEHOLD CURRENTLY RECEIVING FOOD STAMP ASSISTANCE? Yes IS ANYONE IN THE HOUSEHOLD RECEIVING SUPPLEMENTAL SECURITY INCOME (SSI)? Yes DOES THE HOUSEHOLD RECEIVE FEDERAL/STATE CASI'-l ASSISTANCE? (Proof Required) Yes (i.e., WIA, TANF, WELFARE TRANSITION, WELFARE TO WORK) ARE YOU RESIDING IN A FACILITY FOR DEPENDENT YOUTH (FOSTER CARE, ETC.)? Yes IS THE ADDRESS LISTED ABOVE YOUR PERMANENT RESIDENCE? Yes HOW MANY MEMBERS ARE IN YOUR HOUSEHOLD? WHAT IS THE TOTAL ANNUAL HOUSEHOLD INCOME? (Proof must be provided for everyone in the household)
No No No No No No No
$__
RELEASE OF INFORMATION I hearby authorize representatives of the Summer Youth Intern Program to obtain information concerning my household's WIA, TANF, Food Stamp, or Social Security information for the purposes of determining eligibility. ALL INFORMATION WILL REMAIN CONFIDENTIAL.
APPLICANT SIGNATURE PARENT/GUARDIAN NAME PRINTED (IF APPLICANTIS UNDER 18 YEARS OF AGE)
PARENT/GUARDIAN SIGNATURE
I
DATE ~/
_ _
(RELATIONSHIPTO APPLICANT)
DATE
IF SELECTED, YOU WILL BE CONTACTED BY MAIL OR TELEPHONE FOR AN INTAKE INTERVIEW. PLEASE CALL (727) 821-4819 EXT. 5232 WITH QUESTIONS OR FOR ADDITIONAL INFORMATION.
_
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Summer Youth Intern Program 2017 COMPLETION OF THIS APPLICATION
DOES NOT GUARANTEE A POSITION
YOU MUST BE AT LEAST 16 YEARS OLD AND NOT OLDER THAN 21 YEARS OF AGE, AS OF APRIL 22,2017. THE TOTAL ANNUAL HOUSEHOLD INCOME WILL BE USED TO DETERMINE ELIGIBILITY.
INCOMPLETE APPLICATIONS
WILL BE DISCARDED.
NO PHOTOCOPIES
WILL BE ACCEPTED.
PLEASE PRINT IN INK: NAME
SSN(ENTIRENUMBER)
___
HOMEADDRESS
__ CITY
HOME PHONE ('--__ ----" EMAILADDRESS: AGE
STATE
ZIP CODE
EMERGENCY/OTHER PHONE ~
_ _
BIRTH DATE
MALE
_
DO YOU HAVE A DRIVER'S LICENSE, LEARNER PERMIT, OR STATE I.D.?
YES
FEMALE
_
NO (MANDATORY REQUIREMENT)
or
DO YOU HAVE A BANK ACCOUNT? YES OR NO (MANDATORY FOR DIRECT DEPOSIT) ARE YOU IN HIGH SCHOOL OR COLLEGE? YES
or
NO IF NO, HIGHEST GRADE COMPLETED?
IF YES, NAME OF SCHOOL OR COLLEGE
CREDITS
PLEASE SELECT EDUCATIONAL CERTIFICATION RECEIVED: MICROSOFT
D HIGH
SCHODL DIPLOMA
------------------
MAJOR INTERNET
__ CAD/CAT
_
D SPECIAL DIPLOMA DCERT. OF COMPLETION DGED D NONE
WHAT TYPE OF JOB ARE YOU INTERESTED? 1.
_
2.
--------------------
RACE (Please select one):
D
WHITE/CAUCASIAN
D
D
NATIVE AMERICAN
DASIAN AMERICAN
D HISPANIC/NON-WHITE
BLACK/AFRICAN AMERICAN D
OTHER
_
ETHNICITY (Please select one): 0 PUERTO RICAN 0 MEXICAN 0 CUBAN 0 OTHER HISPANIC
o HAITIAN 0 INONE OF THE ABOVE THE FOLLOWING INFORMATION WILL HELP US DETERMINE YOUR ELIGIBILITY FOR THE SUMMER PROGRAM: 1. 2. 3. 4. 5. 6. 7. 8. ~.
HAVE YOU EVER HAD A JOB? Yes HAVE YOU EVER BEEN ARRESTED/PENDING CHARGES? (Background checks mandatory) Yes IS YOUR HOUSEHOLD CURRENTLY RECEIVING FOOD STAMP ASSISTANCE? Yes IS ANYONE IN THE HOUSEHOLD RECEIVING SUPPLEMENTAL SECURITY INCOME (SSI)? Yes DOES THE HOUSEHOLD RECEIVE FEDERAL/STATE CASI'-l ASSISTANCE? (Proof Required) Yes (i.e., WIA, TANF, WELFARE TRANSITION, WELFARE TO WORK) ARE YOU RESIDING IN A FACILITY FOR DEPENDENT YOUTH (FOSTER CARE, ETC.)? Yes IS THE ADDRESS LISTED ABOVE YOUR PERMANENT RESIDENCE? Yes HOW MANY MEMBERS ARE IN YOUR HOUSEHOLD? WHAT IS THE TOTAL ANNUAL HOUSEHOLD INCOME? (Proof must be provided for everyone in the household)
No No No No No No No
$__
RELEASE OF INFORMATION I hearby authorize representatives of the Summer Youth Intern Program to obtain information concerning my household's WIA, TANF, Food Stamp, or Social Security information for the purposes of determining eligibility. ALL INFORMATION WILL REMAIN CONFIDENTIAL.
APPLICANT SIGNATURE PARENT/GUARDIAN NAME PRINTED (IF APPLICANTIS UNDER 18 YEARS OF AGE)
PARENT/GUARDIAN SIGNATURE
I
DATE ~/
_ _
(RELATIONSHIPTO APPLICANT)
DATE
IF SELECTED, YOU WILL BE CONTACTED BY MAIL OR TELEPHONE FOR AN INTAKE INTERVIEW. PLEASE CALL (727) 821-4819 EXT. 5232 WITH QUESTIONS OR FOR ADDITIONAL INFORMATION.
_
I
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"Um::o ~»~ (/)"UZ -"UG) ~CCJ m(')oo( O1~:s: 0-» ::00OZl »z"U :s:»r e;z~ mm(/) ozm »"TI
m-..J 0"100"100000"1::3 000000000
sn
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=3 ~. 0
::>
rn
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:l :l 0
-I rno >< c (") (/)
CD CD CD:::Y
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» Z 01 III
c.Q_ :::Ym CD P:J
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::::l
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CD
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