Youth Employment Application

I certify that my answers are true and complete to the best of my knowledge.

To: All Employers in the State of Ohio From: Ohio Department of Commerce, Bureau of Labor and Worker Safety Subject: Minor Wage Agreement

Section 4109.10 of the Ohio Revised Code reads as follows:

“No employer shall give employment to a minor without agreeing with him as to the wages or compensation he shall receive for each day, week, month, or year; or per piece, for work performed. The employer shall furnish the minor with written evidence of the agreement and on or before each payday, with a statement of the earnings due and the amount to be paid to him. No employer shall reduce the wages or compensation of any minor without giving him notice at least twenty-four hours previous to the reduction, at which time a written agreement shall be entered into with the minor as in the case of original employment.” The following form is furnished as a guide or sample, and may be reproduced by any employer. This form should be prepared in duplicate and signed by both the employer and the minor. One copy to be given to the minor and the other copy to be retained by the employer in the personnel file of the minor.

a minor who is under 18 years of age and agree that minor shall be paid at the rate of $15 per hour. We also have on file a working certificate for said minor, unless otherwise exempt under Chapter 4109.

I hereby certify that to the best of my knowledge and belief, the above statements are true and that the minor named above may work with my approval.

Minors aged sixteen or seventeen who are to be employed during summer vacation months after the last day of the school term in the spring and before the first day of the school term in the fall, in nonagricultural and nonhazardous employment as defined by the ''Fair Labor Standards Act of 1938'', 52 Stat. 1060.29 U.S.C.A. 201, and similar state statutes, or in other employment not prohibited to minors age sixteen or seventeen by law, shall not be required to provide an age and schooling certificate as a condition of employment. In order to be hired for employment during summer vacation months, such minors shall provide the employer with the following:

(1) Evidence of proof of age in the same manner as proof of age is provided the superintendent of schools under division C of section 3331.02 of the Revised Code.

(2) A statement signed by the minor's parent or guardian consenting to the proposed employment during the summer vacation months. For the purpose of this section, in the absence of a parent or guardian a person over eighteen years of age with whom the minor resides may sign such statement.

The employer shall retain a copy of the proof of age and the statement of consent with the minors employment records.

 

Bureau of Wage and Hour Administration

6606 Tussing Road Reynoldsburg, OH 43068-9009 LAW1008

An Equal Opportunity Employer and Service Provider 614-644-2239 Fax 614-728-8639 TTY/TDD 800-750-0750 com.ohio.gov

 

 I, the undersigned, acknowledge that I am voluntarily seeking to become a participant in a program funded under the Temporary Assistance for Needy Families (TANF) program, Workforce Innovation and Opportunity Act (WIOA), and Comprehensive Case Management and Employment Program (CCMEP) administered by Franklin County Department of Jobs and Family Services (FCDJFS) and the Workforce Development Board of Central Ohio (WDBCO) through the A.M.P (Achieve More & Prosper) program.

I hereby release, discharge and otherwise agree to indemnify Lead The Way Learning Academy and the respective Program Partners, all A.M.P worksites, their officers, board members, employees, agents and volunteers from any and all liability for any harm, claims, costs, injury and/or property damage arising out of or related to my child/ward’s/ward’s participation in the program. I further agree to indemnify and hold harmless Lead The Way Learning Academy and the Program Partners from and against any loss, liability, damage or cost, including court costs and attorneys’ fees that may arise due to my child/ward’s participation in the program.

1. Sharing of Information
I authorize any person, organization or agency (such as Franklin County Department of Jobs and Family Services (FCDJFS), the Ohio Department of Jobs and Family Services (ODJFS), Lead The Way Learning Academy (LTWLA), secondary schools, post-secondary schools, employers, etc.) having information concerning my goals, objectives, work experience, education, interests, and program completion outcomes, to share any such information that may be pertinent to my participation in any WIOA and CCMEP program with any other person or agency having a need for such information. In particular, I authorize the sharing of such information with Lead The Way Learning Academy.

2. Job Placement and Follow-Up
I agree to provide Lead The Way Learning Academy with information regarding my education and employment status, once I have completed the FCDJFS funded program to maintain compliance with eligibility standards related to programming. Further, I authorize any party to release information that will allow Lead The Way Learning Academy to comply with the U.S. Department of Labor guidelines and regulations that require up to 12 months of follow-up on all program participants. This includes the authorization of FCDJFS, ODJFS, my employers, secondary school, post-secondary schools, and my training providers to release such information to each other.

3. Confidentiality
I understand that Lead The Way Learning Academy will only solicit information necessary and relevant to my participation in A.M.P FCDJFS-funded programs and will treat such information as confidential. Information will not be released to any unauthorized person, organization or agency.

4. Medical Treatment
I hereby release, discharge and otherwise agree to indemnify Lead The Way Learning Academy and the respective Program Partners, their officers, board members, employees, agents and volunteers from any and all liability for any harm, claims, costs, injury and/or property damage arising out of or related to my child/ward's/ward's participation in the program. I further agree to indemnify and hold harmless Lead The Way Learning Academy and the Program Partners from and against any loss, liability, damage or cost, including court costs and attorneys' fees that may arise due to my child/ward's participation in the program. Further, I hereby grant to Lead The Way Learning Academy and the respective Program Partners, representatives or their designee(s), the right to consent on my child/ward’s behalf for medical treatment if neither I nor my child/ward’s emergency contact(s) are unable to do so. I understand that my emergency contact will be notified of any emergency situation immediately, but that I give this emergency medical release to necessary parties in the event that my emergency contact is unavailable and immediate authorization for treatment is required. I grant to Lead The Way Learning Academy and the respective Program Partners, representatives or designee(s) the right to transport my child/ward to any emergency medical or health care facility for immediate treatment and/or consultation, if necessary.

5. Right to Appeal
I understand that I have the right to appeal any determination that affects my participation in the FCDJFS and WDBCO-funded program through the WIOA
Complaint Rights process and/or the grievance policy.

6. Consent to Use Image
In the event that I am selected as a participant, I grant Lead The Way Learning Academy the right to photograph me while I am enrolled in a CCMEP program. I understand that photographs will be used for promotional advertisements or other displays promoting FCDJFS and WDBCO-funded programs or other related activities. This may expand but is not limited to video, and other audio-visual materials for which I will not receive compensation.

Check one please:

I understand that my child/ward has the opportunity to voluntarily participate in planned A.M.P. Program activities. I understand and accept the risks associated with these activities.

Further, I hereby grant to Lead The Way Learning Academy and the respective Program Partners, representatives or their designee(s), the right to consent on my child/ward's behalf for medical treatment if myself or my child/ward's emergency contact(s) are unable to do so. I understand that my emergency contact will be notified of any emergency situation immediately, but that I give this emergency medical release to necessary parties in the event that my emergency contact is unavailable and immediate authorization for treatment is required. This release is effective for the duration of the program.

I hereby give permission for my child/ward to participate in the A.M.P. Program, as administered by Lead The Way Learning Academy and the respective Program Partners.

Having received and reviewed pertinent information about the program, I acknowledge that it is my responsibility as the parent/guardian of my child/ward to evaluate carefully the risks inherent in participation in this program. I understand that my child/ward has the opportunity to voluntarily participate in A.M.P. Program including relevant activities and workshops. I have fully considered the risks of participation in such activities, including but not limited to dangers posed by willful or negligent conduct by my child/ward and/or others. I understand and agree that, while there will be appropriate adult supervision during the course of the program, there may be times when no supervision will be provided (i.e., when students are traveling to and from the program). I recognize that my child/ward may be at risk for accident or injury arising from negligence or otherwise during her participation in the A.M.P. Program. I hereby release, discharge and otherwise agree to indemnify Lead The Way Learning Academy and the respective Program Partners, its officers, board members, employees, agents and volunteers from any and all claims of injury and/or property damage arising out of or related to my child/ward's/ward's participation in the program.

I agree that if any portion of this document is held invalid, the remaining provisions shall be binding and continue in full force and effect. In consideration of my participation in the A.M.P. Program, the undersigned hereby agrees to assume all responsibility for personal injuries and insurance to cover any injuries or illness occurring while attending the A.M.P. Program or while staying in facilities operated within by Lead The Way Learning Academy and the respective Program Partners harmless for any and all liability, actions, causes of actions, debts, claims and demand of every kind and nature whatsoever, which arises from or in connection with trainee duties and voluntarily assumes all risks that are not latent or created by staff.

The undersigned understands that Lead The Way Learning Academy and the respective Program Partners liability insurance, health, accident, workers compensation or life insurance does not cover the program participant.

I understand that my child/ward has the opportunity to voluntarily participate in planned Franklin County Jobs and Family Services and Workforce Development Board of Central Ohio A.M.P. / CCMEP activities. I understand and accept the risks associated with these activities.

In the event reasonable attempts to contact the above are unsuccessful, the undersigned hereby gives consent for (1) administration of any treatment
deemed necessary by:

Or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the student to:

 Personal health and accidental injury insurance as indicated below cover the undersigned trainee:

These Terms & Conditions apply to all programs run by Lead The Way Learning Academy including but not limited to the A.M.P. Program.

Lead The Way Learning Academy does not share email addresses or any other personal information with third parties interested in contacting or collecting information from program participants and their parents/guardians. Furthermore, Lead The Way Learning Academy DO NOT sell, rent, give or trade personal information we collect from online, phone or paper registrations.

Lead The Way Learning Academy will not release any information regarding your child to any third party with the exception being appropriate medical personnel during a medical situation/emergency.

Lead The Way Learning Academy stores participant and parent/guardian’s personal information in secure operating environments that are not available to the public. This personal information is accessible only by the participant, parent, guardian and select Lead The Way Learning Academy employees. These employees are bound by duties of confidentiality and have access to select databases, which are further protected by Lead The Way Learning Academy and password requirements.

Lead The Way Learning Academy requires criminal background checks for all Instructors and other staff who will be on-site for any duration of time. LTWLAtakes the safety and security of its participants very seriously and requires criminal background checks for anyone authorized by Lead The Way Learning Academy to be in contact with your child for the duration of programming.

All pictures taken at or in connection with the Youth Employment Program are the sole and exclusive property of Lead The Way Learning Academy and may be used by the organization in any promotional materials and other print media for camp and organization purposes. LTWLA not sell or distribute these photos for any other purposes than those listed above. Participants and guardians understand that all images, video and audio taken at or in connection with the A.M.P Program are the sole and exclusive property of Lead The Way Learning Academy and may be used by Lead The Way Learning Academy in promotional materials, marketing collateral, and online media for programming purposes. These images, videos and audio may be shared and used by corporate partners, the media, or other organizations who work with Lead The Way Learning Academy. Please note that at times, Lead The Way Learning Academy is contacted by the press, and a student’s full name may be used in print, radio, TV and other mediums.

Lead The Way Learning Academy reserves the right to modify its Privacy Policy at any time. In the event that LTWLA make a material modification to our policy, the “Updated” date at the bottom of this page will be changed to reflect the date of the modification and updates will be redistributed.

I hereby grant permission for Lead The Way Learning Academy to share my child/ward’s program information (name, date of birth, student ID) with Columbus City Schools, KIPP Columbus, Reynoldsburg City Schools, United Schools Network and Whitehall City Schools, Groveport City School, and starting to implement Graham or other Program Partners. I understand that information will only be shared about my child/ward if it is relevant to my child/ward’s education. The community program may also request access to my child/ward’s academic, attendance and behavior records at Columbus City Schools and Whitehall City Schools so that they can provide better services to my child/ward. I understand that this information will be kept confidential but will be shared as requested.

Upon registration, I will need to submit information regarding all of the following information about my child/ward, including: allergies, illnesses, medications, dietary restrictions, and emergency contact information.

We ask for the physician’s name, along with the physician’s contact information. Additionally, it is required that you provide the medical insurance carrier. If your child is not covered under a health insurance plan or if you do not wish to provide us with your medical insurance information, you must agree to accept all financial liability should your child become injured while in the care of Lead The Way Learning Academy and release Lead The Way Learning Academy from any such financial responsibility.

As the parent/guardian, I give permission to Lead The Way Learning Academy staff to seek emergency medical or surgical treatment and
hospitalization, if necessary. I will be financially responsible for any medical attention needed during camp or resulting from any injury received at camp. My medical insurance shall be the insurance coverage for any medical treatment. I understand that every attempt will be made to contact you, or the emergency contact(s) named,  before taking this action and give permission to the program to arrange necessary related transportation for your child.

Lead The Way Learning Academy staff and instructors are not authorized to give any student any prescription or over-the-counter medication. Please refrain from bringing any medication, i.e. vitamins and/or supplements to work. We ask that students please take ALL medication and/or vitamins before programming. Our policy does not allow for any participant with an acute illness to attend work on those days which obligate the child to take medication during work hours. Any child ill enough to require medication should remain at home under parental supervision or arrange with the child’s physician a regimen that allows the medication to be administered before and after work.

All individuals and their property are to be valued and treated with respect.

All individuals have the right to a safe, secure and cooperative environment in which participation, risk taking and confronting challenges are encouraged.

Staff should be able to perform their duties in an atmosphere of order and cooperation. Staff, students and the natural environment have the right to exist in a healthy and environmentally considerate atmosphere. Lead The Way Learning Academy expects support from all students, parents, guardians and staff in implementing this Code of Conduct.

All students should treat one another, staff and property with respect.

All students should conduct themselves in a way which does not endanger, intimidate or interfere with the participation of others.

Students should comply with instructions given by any Lead The Way Learning Academy staff and should willingly participate in the daily routine of the A.M.P. Program.

All students should conduct themselves in a healthy and friendly manner towards other students and staff.

All students should behave according to this Code and accept the consequences if it is breached. All staff should fairly, reasonably and consistently implement this Code. Staff and parents should support the implementation of the Code of Conduct.

You acknowledge that if upon observation of your student, if it is determined by the Instructors and Lead The Way Learning Academy staff that the A.M.P. Program is not a suitable and productive environment to develop and honor your student, Lead The Way Learning Academy may dismiss your child. Lead The Way Learning Academy will exhaust every opportunity for an excellent relationship with each and every participant. If possession of illegal substances or weapons is suspected, student(s) will be subject to search and seizure. If possession of illegal substances or weapons is found, students(s) will be dismissed from the program immediately.

YOU HEREBY WAIVE AND RELEASE LEAD THE WAY LEARNING ACADEMY, ITS BOARD OF TRUSTEES, EMPLOYEES, CONTRACTORS, SPONSORS, PARTNERS, AND FACILITY PROVIDERS AND THEIR BOARD OF TRUSTEES, EMPLOYEES, CONTRACTORS, SPONSORS, PARTNERS, FROM LIABILITY FOR ANY INJURY OR ILLNESS INCURRED DURING MY CHILD/WARD’S PARTICIPATION DURING THE PROGRAM. YOU UNDERSTAND THAT THERE IS RISK OF INJURY TO THE NAMED
STUDENT AS A RESULT OF CAMP ACTIVITIES, AND KNOWINGLY AND VOLUNTARILY ASSUME ALL RISK OF SUCH INJURY.

By submitting the information, it certifies that you, the Parent/Guardian, agree to the terms stated above, and have taken the time to ensure that ALL information in the HEALTH INFORMATION AND EMERGENCY CONTACT INFORMATION SECTIONS ARE UP-TO-DATE AND ACCURATE TO THE BEST OF YOUR KNOWLEDGE.

ON BEHALF OF YOUR CHILD/WARD, YOU HEREBY RELEASE LEAD THE WAY LEARNING ACADEMY, ITS BOARD OF TRUSTEES, EMPLOYEES, CONTRACTORS,  SPONSORS, PARTNERS, AND FACILITY PROVIDERS AND THEIR BOARD OF TRUSTEES, EMPLOYEES, CONTRACTORS, SPONSORS, PARTNERS FROM LIABILITY (INCLUDING CLAIMS BASED UPON NEGLIGENCE) FOR DAMAGE OR INJURY TO YOUR CHILD/WARD OR DAMAGE OF ANY PERSONAL PROPERTY, ACCEPTING YOURSELF THE FULL RESPONSIBILITY FOR ANY AND ALL SUCH DAMAGE OR INJURY WHICH MAY RESULT DIRECTLY OR INDIRECTLY FROM ANY NEGLIGENT ACTS OR ACTIVITIES ASSOCIATED WITH LEAD THE WAY LEARNING ACADEMY AND ITSPROGRAMS. HOWEVER, YOU UNDERSTAND THAT YOU ARE NOT RELEASING LEAD THE WAY LEARNING ACADEMY, ITS BOARD OF TRUSTEES, EMPLOYEES, CONTRACTORS, SPONSORS, PARTNERS, AND FACILITY PROVIDERS FROM GROSS NEGLIGENCE, RECKLESS CONDUCT OR INTENTIONALLY TORTIOUS CONDUCT. TO THE EXTENT THIS RELEASE CONFLICTS WITH STATE/PROVINCE LAW GOVERNING RELEASES, THIS RELEASE IS TO BE GIVEN THE FULLEST FORCE AND EFFECT PERMITTED UNDER STATE/PROVINCE LAW. IF THIS RELEASE IS DETERMINED TO BE INVALID UNDER THE LAWS OF THE GOVERNING STATE/PROVINCE, THEN THIS RELEASE SHALL BE STRICKEN FROM THIS CONTRACT, BUT ALL OTHER TERMS AND CONDITIONS OF THIS AGREEMENT SHALL REMAIN IN FULL FORCE AND EFFECT.

Lead The Way Learning Academy does not owe a duty to protect its participants from theft or damage to property. You will not hold Lead The Way Learning Academy responsible for any lost, stolen, or damaged personal items brought to programming sites. If any theft of or damage to your child/ward’s property should occur at camp, or in association with the camp, you understand that Lead The Way Learning Academy will not be held responsible. You agree that as the parent/guardian of the named Student, you certify that your son/daughter/ward has your permission to attend and participate in the Lead The Way Learning Academy program. The camp has the right to dismiss any individuals if their actions or attitudes are deemed detrimental, as set forth in Lead The Way Learning Academy Student Code of Conduct. You further understand that you will be responsible for personal or property damage incurred by your son/daughter/ward while at camp and that Lead The Way Learning Academy is not responsible for personal belongings lost or damaged by casualty, theft, etc.

If you have any questions or comments about our Terms & Conditions, please contact us at 614.915.0434.