WIOA Youth Application

ATTESTATION

I understand that, by signing this form, I certify that all information provided is true. Any willful misstatement of facts may cause forfeiture of my participation in the WIOA program. I understand the information is subject to verification and agree to provide such documentation as required. I understand my Social Security number may be given to other Federal, State, and Local government or non-government job training agencies for performance tracking.
Participant Signature

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Parent/Guardian (if under 18) Signature

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*PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of your socialsecurity number is mandatory. Social security numbers will be used by the Agency for program administration including verificationpurposes, distinguishing one individual from another, and for tracking and reporting purposes.
CareerSource Pasco Hernando is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.

CSPH Youth Program - Household Composition Form

Please list all core family members that are living in your house, starting with yourself. Please indicate each person’s relationship to you. Also indicate whether any family members have worked in the last six (6) months.*

	Name	Relationship to Participant	Worked in the Last 6 Months	SS Number
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I certify that all information provided on this form is true and correct. I consent to verification of this information. I further understand that his information will be used to determine my eligibility to enter the WIOA Youth Program and that any false information given intentionally may result in my immediate termination from the WIOA Youth Program and that any monies received while enrolled in the WIOA Youth Program may have to be repaid.

Clear
*PRIVACY ACT STATEMENT: Pursuant to 42 U.S.C. 1320b-7 (a) (1) (Social Security Act) and 7 C.F.R. 273.6, disclosure of yoursocial security number is mandatory. Social security numbers will be used by the Agency for program administration includingverification purposes, distinguishing one individual from another, and for tracking and reporting purposes.
CareerSource Pasco Hernando is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers listed may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.

Release/ Grievance/ Attestation Form:
RELEASE OF INFORMATION
I hereby authorize all partners in the Pasco Hernando Regional Workforce Development Board’s CareerSource Pasco Hernando System to engage in verbal, written, facsimile, or computerized communication of information for the purpose of making me eligible for services or for identifying services or agencies to assist me. All pertinent records and information can be released including those regarding past, present, or future information or records that may be needed for eligibility determination, monitoring or follow-up purposes. It is my understanding that any information obtained by any partner in the CareerSource Pasco Hernando System will be held in strict confidence. I am aware that any information will be used in my best interest to provide ease of access to services.

ATTESTATION
I hereby certify, to the best of my knowledge, the information provided is true. I agree and understand any willful misstatement of facts may cause forfeiture of my status in the Workforce program and could be cause for legal action. I understand the information is subject to verification and agree to provide such documentation as required. I understand my social security number may be given to other federal, state, and local government or non-government job training agencies for performance tracking purposes.

DISCRIMINATION PROCEDURES

EQUAL OPPORTUNITY IS THE LAW

If you, as a Workforce Customer, feel that your rights are being violated due to an act of discrimination based on race, color, sex, national origin, religion, age, political affiliation or belief, marital status, citizenship or disability, you may file a discrimination complaint directly with CareerSource Pasco Hernando's Equal Opportunity Officer (contact information listed below), Florida Commerce, Office of Civil Rights, Caldwell Building, 107 East Madison Street, MSC 150, Tallahassee, FL 32399-4128, or with the US Department of Labor, Civil Rights Center, 200 Constitution Avenue Northwest, Room N-4123, Washington, DC 20210, within 180 days of the alleged occurrence.

GRIEVANCE/COMPLAINT PROCEDURES

If you feel you have been adversely affected by a decision or action made by CareerSource Pasco Hernando, you have the right to file a written grievance/complaint to CareerSource Pasco Hernando’s Equal Opportunity Officer(contact information listed below).Information on filing a grievance/complaint can be obtained from the CareerSource Pasco Hernando’s Equal Opportunity Officer. After the opportunity for a hearing (within 60 days after formal filing), if you are dissatisfied, you may appeal to Florida Commerce, Office of General Counsel, Caldwell Building, Suite 150, 107 East Madison Street, Tallahassee, FL 32399-4128.

Administrative Entity:

CareerSource Pasco Hernando, 16228 Spring Hill Dr. Brooksville, Florida 34604
Brandy Taylor, Equal Opportunity Officer (352) 593-2227 Email: btaylor@careersourcepascohernando.com
I certify that I have received a copy of and understand my rights and responsibilities as enumerated in this statement.

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Applicant's Signature
I verify that the above signed participant read or had read to him/her, and received a copy of this statement enumerating CareerSource Pasco Hernando’s Grievance/Complaint Procedures and Release of Information.

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Verifying Official
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers listed above may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.
Should be Empty:

WIOA Youth Application

Applicant Information:

Parent/ Guardian (if under 18):

Applicant Information:

Education:

Basic Skills:

Applicant Information:

Family Size:

Parent must be listed on birth certificate/ legal record/ public assistance record

ATTESTATION

CSPH Youth Program - Household Composition Form

Release/ Grievance/ Attestation Form: