2023 SYEP at Isaacs Application

Thank you so much for your interest in the Isaacs Center's Community Health and Wellness Summer Youth Employment Program (SYEP)!

We have a total of 50 spots that will be given on a first-come, first-served basis. Everyone, even prior SYEP'ers, will need to complete the application.

Participants will need to commit to an orientation before being officially accepted into the program.

Once you have completed the application, we will send you a confirmation email & text that includes your unique Application ID Number. You will use this number to upload requested documents into the SYEP Document Upload system, which we will provide instructions for. Please see the graphic at the end of this application that details the documents we'll be collecting this year.

Applications and documents are due on March 31st, 2023.
PERSONAL INFORMATION
Name

First NameMiddle InitialLast Name
2.Today's Date

MonthDayYear
Date
3.Social Security Number
4.Date of Birth (Month/ Day/ Year)

MonthDayYear
Date
Age
Please note that in order to be eligible for this particular SYEP program, you must be between the ages of 16-24 years of age by July 6th, 2023.

If this message remains on the screen after you have entered your date of birth, this means that you are not eligble for the program. If you have any questions or feel that you have recieved this message in error, please contact us at ewinfo@isaacscenter.org
5.Your Home Phone Number

Country CodeArea CodePhone Number
6.Your Cell Phone Number

Country CodeArea CodePhone Number
7. Your E-mail Address
example@example.com
Would you like to receive text updates?
Legal Parent/Guardian

9. First Name of Parent or Legal Guardian8.Last Name of Parent or Legal Guardian
10. What is your race?
11. What is your ethnicity?
12. What is your sex at birth?
13. What is your gender identity?

Another Gender
14. Does Applicant identify as transgender?
Transgender is an umbrella term for people whose identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. Some transgender people will identify with the opposite gender they were assigned at birth, and some may not identify with any binary gender. Someone who identifies their gender as androgynous, gender queer, non-binary, gender non-conforming, MTF or FTM may also consider themselves to be transgender.
SYEP PRIDE (Optional)

SYEP Pride will work toward a future without discrimination where all people have equal rights to employment.We will work with youth and businesses alike to produce LGBTQ+ Pride opportunities that inspire, educate, commemorate, and present a level field for a diverse community. SYEP Pride will connect people between the ages of 14-24 who identify as LGBTQ+ with supportive, safe, and affirming work and career exploration experiences.
By opting in, you are affirming that you are willing to participate in the inaugural SYEP PRIDE program.
15. What Are Your Gender Pronouns?

Another Pronoun
16. What Is Your Sexual Orientation?
17.Selective Service Registration Number
Males 18 years of age or older must be registered with the Selective Service System to participate in the program (if you have not registered yet, please visit www.sss.gov)
Date of Registration

MonthDayYear
Date
18. *Applicants 18 or Older* Are You a Veteran?
19. *Applicants 18 or Older* Are You an Active Military Applicant?
20. How Well Do You Speak English?
21.Please Enter Your Primary Language
22.Other Languages Spoken by You: (Check All That Apply)

Other
HEALTHCARE INFORMATION
23. Do You Have Health Insurance?
25. If NO, Would You Like to Be Contacted About Signing Up for Public Health Insurance? (Select One)
24. If YES, Please Specify The Health Insurance Down Below (Check All That Apply)
HOUSEHOLD INFORMATION
26.You Live in a Household That Is Headed By (Select One):

Other
27.What is Your Household Size?
28. Total Household Income in The Last 12 Months?
29.Please Check This Box If You Have No Household Income:
29a. Please Select Your Housing Type:

Other
29b. If You Live In NYCHA, Please Specify The NYCHA Development Here
30. What is Your Current Work Status (Select One)?
31a. Are You or Your Family Currently Receiving Public Assistance?
31b. If YES, Please Specify Type of Public Assistance:

Other
32. Enter Your Full Address Here

Street Address Line 2

CityState / Province

Zipcode
Borough
33. Do You Have Access to An Electronic Device With Internet Accessibility?
34. Do You Have a Bank Account?
35. If NO, Are You Interested In Opening a Bank Account?
36. Are You Interested In Direct Deposit?
EMERGENCY CONTACT INFORMATION
Contact 1
Contact Name
Relation to Applicant
Email Address
example@example.com
Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Contact 2
Contact Name
Relation to Applicant
Email Address
example@example.com
Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
ADDITIONAL QUESTIONS

Please Select Your Citizenship Status

Other
46.How Did You Hear About Us?
EDUCATIONAL STATUS & CAREER DETAILS
47. What is Your Education Status?
8. Where Is Your School Located?
City & State of School
49.What is Your School Major?
50.What is Your Current/ Last Grade Completed?
57. Are You Familiar with Any of These Skills? (Check All That Apply)
51a. Please Enter the Start Date of Your Summer Break

MonthDayYear
Date
51b. Please Enter the End Dates of Your Summer Break

MonthDayYear
Date
52.GPA / GPA Equivalent
Enter "NA" if this does not apply
53.Name of School or Academic Institution
54. Please Indicate the School System You Attend:

Other
55.Current DOE Students only OSIS #
56. Do You Have Prior Work Experience (Paid or Unpaid)?
58. What Is Your Long- Term Career Goal? Please List Three (3) Interests:
59. Are you a Current DOE D75 Student?
60. Do You Have an Individualized Education Program (IEP)?
Certification of Accuracy: 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.
Signature
Date

MonthDayYear
Date
Parent/SignatureGuardian
Date

MonthDayYear
Date
OLDER YOUTH DOCUMENT CHECKLIST - Please take a screenshot or save for future reference
Should be Empty:

Rows	Yes	No
37. Are You Currently In The Foster Care System?
38. Are You a Parent or a Guardian?
39. Do You Have a Disability?
41. Are You Currently a Runaway?
42. Are You Currently Homeless?
43. Are You an Offender or Court Involved?
44. Are You Receiving ACS Preventative Services?
45. Are you a Gender-Based/ Domestic Violence Victim?

PERSONAL INFORMATION

SYEP PRIDE (Optional)

HEALTHCARE INFORMATION

HOUSEHOLD INFORMATION

EMERGENCY CONTACT INFORMATION

Contact 1

Contact 2

ADDITIONAL QUESTIONS

EDUCATIONAL STATUS & CAREER DETAILS

OLDER YOUTH DOCUMENT CHECKLIST - Please take a screenshot or save for future reference