PARENT CONSENT FORM

NAN Application
Confirmation Number:*
PARENT CONSENT FORM

(W-9, Insurance, Handbook)
I give consent for my child, First NameLast Name to be a W-9 employee, therefore named as a contractor. I understand that no taxes will be taken out and he/she will be responsible for any obligations to the state or federal government.
Signature of Parent / Guardian
Date

MonthDayYear
Date
I understand that as a contractor, First NameLast Name and all others associated with this program are not responsible for any injuries or such and if such injuries do arise my child’s insurance is responsible for all medical bills.
Signature of Parent / Guardian
Date

MonthDayYear
Date
I have read the NAN AC employee handbook and I am in accordance with all of the rules and regulations of the program and will ensure that my child will comply with all such rules. First Name Last Name
Signature of Parent / Guardian
Date

MonthDayYear
Date

NAN AC

Application Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Date of Birth

MonthDayYear
Date
Age
Phone Number
Please your phone number.
Emergency Phone Number
Please enter your emergency contact number.
Social Security Number
School
Grade
Parent / Guardian Name

First NameLast Name
Parent / Guardian Name Phone Number
Please your parent / guardian phone number.
Employment History

Please list last (3) employers
Check "Yes" here if you have never worked.

Yes
Employer and Position
Year
Employer and Position
Year
Employer and Position
Year
References

Please provide two (2) references. No relatives
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
How did you hear about us?
I certify that the information I have submitted is true & accurate
Signature of Applicant
Date

MonthDayYear
Date

Photographing and Videotaping Permission Slip
NAN AC would like to document its activities with our participants by photographs, slides, and videotapes. These pictures and slides would be taken by elders of the program or supervised volunteers, and would only be taken during organized activities sponsored by the program.

These pictures and slides would be used to:
(a) add to the Scrapbook for an historical documentation of activities,
(b) use at later Train to Work Workforce Development meetings as teaching/learning tools,
(c) show and or display at Parent’s Meetings, ceremonies and press releases
(d) promote activities in promotional materials and/or in the news media:
In regard to having my child photographed or videotaped during Train to Work Workforce Development Program activities: (Check those that apply)

I prefer that my child not be photographed or videotapedI give my permission for my child to be photographed and videotaped.I would be interested in copies of prints or slidesI would be interested in copies of videotapes
In addition,

I prefer that my child’s photograph or likeness on videotape is not to be used in Train to Work Workforce Development Program promotional literature or in the news media.I give my permission for my child’s photograph or likeness on videotape to be used in all Train to Work Workforce Development Program promotional literature and/or in the news media.
Signature of Parent / Guardian
Date

MonthDayYear
Date
I have read and understood the information above and consent to those selections indicated by my parents.
Signature of Youth
Date

MonthDayYear
Date

Beneficiary Self-Certification Form

Atlantic City CDBG Program - For Public Service Projects (2025 Income Limits)
Program Name
Program Date

MonthDayYear
This program has received assistance from Atlantic City through funds that were provided in part by the U.S. Department of Housing and Urban Development (HUD) which requires that the following information be completed. This information will be kept confidential.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Size
Sources of Income
In the chart below, find your family size, then circle the income level for your family’s current annual income. Total family income includes income from all sources (wages, unemployment, social security, public assistance, interest and dividends, worker’s comp, etc.) for all members of your family who are at least 18 years of age. A family is defined as all persons living in the same household who are related by birth, marriage, or adoption.
Higher family income

My family income is higher than the amounts listed above for my family size. (Check the circle only if it applies)
My family income is
Race (must check one)

WhiteBlack/African AmericanAsianAmerican Indian/Alaskan NativeNative Hawaiian/Other Pacific IslanderOther Multi-Racial
Ethnicity (must check one)

HispanicNon-Hispanic
I attest that the information provided is true and correct to my knowledge. I understand that the information listed on this form may be subject to verification by Atlantic City and/or by the U.S. Department of Housing and Urban Development (HUD), the Office of the Inspector General, or their authorized representatives.
Beneficiary Signature
Date

MonthDayYear
Date
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.

Transportation Waiver of Liability & Registration Form

Train to Work Workforce Development Program
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Message
Birthdate

MonthDayYear
Date
Age
Waiver of Liability
In consideration of the benefits to be derived by ___________________________________ from the Train to Work Workforce Development program included but not limited to bus trips, games, activities, etc. I hereby waive any and all rights of actions, suits, claims or demands whatsoever against the Train to Work Workforce Development program or its affiliates, officials or employees which might arise out of participation in the Train to Work Workforce Development program. I assume the risk of all dangerous conditions that do exist and waive any and all specific notice of the existence of such conditions.
Date

MonthDayYear
Date
Signature of Parent / Guardian
Medical Release
Minor's Name

First NameLast Name
Sex
Minor's Physician

First NameLast Name
Allergies
Existing Medical Conditions
Procedure to follow in event of an emergency
I hereby grant authorization to the staff of the . to render treatment that it deems necessary in the event that _____________________________________________ is injured and we, the parents or guardians, are not able to be contacted or notified in sufficient time. I have been informed as to the significance of this authorization and freely give same. The Train to Work Workforce Development program provides no health insurance. The responsibility for adequate health insurance coverage rests solely with the parent/guardian.

I, the Parent/Guardian of the above named minor, in witness whereof, have hereunto set my hand and seal on this date

Of _______________________, signed sealed and delivered in the presence of:
Signature of Witness
Signature of Parent / Guardian
Should be Empty:

NAN Application

PARENT CONSENT FORM

NAN AC

Employment History

References

Photographing and Videotaping Permission Slip

Beneficiary Self-Certification Form

Transportation Waiver of Liability & Registration Form

Waiver of Liability

Medical Release