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  • WIOA Youth Application

    This form is hosted on a secure, HIPAA-compliant platform. All information submitted is encrypted and kept confidential.
  • Are you completing this application with the intention of participating in the Summer Youth Employment Program (SYEP)?

  • Applicant Information:

  • Date of Birth*
     / /
  • Current Date
     / /
  • Are you currently attending school*
  • Select all that apply:*
  • County of Residence*

  • Parent/ Guardian (if under 18):

  • Format: (000) 000-0000.

  • Applicant Information:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Race*
  • Are you of Hispanic, Latino, or Haitian heritage?*
  • Limited English: Do you have difficulty reading, writing, or speaking English?*
  • Are you authorized to work in the United States?*
  • Lawfully Admitted Alien/Refugee*
  • Expiration Date:
     - -
  • Do you need support related to substance use or recovery?*
  • Youth Requires Additional Assistance (RWB Local Barrier)*
  • Have you been involved with the juvenile or criminal justice system?*
  • Selective Service Registration*

  • If yes to Considered to have a disability, the WIOA program must have within Employ Florida the documentation of verification of Disability. One of the following are allowable documentation: (Letter from drug or alcohol rehabilitation agency, Medical Records, Social Service records/referral, Physician's Statement, Psychiatrist's statement, Psychologist's diagnosis, Rehabilitation evaluation, School records, Sheltered workshop certification, Workers' Compensation record, Social Security Administration disability records, veterans Administration Letter/records, Applicant statement or Social Service Records/referral.

  • If yes to considered to have a disability, indicate impairment type:

  • Education:

  • Dropout
  • Date Left School*
     / /
  • High School Graduate*
  • GED*
  • Date Obtained
     - -
  • Needs GED*
  • Currently Attending School:*

  • Basic Skills:

  • Basic Skills Deficient/ Low Levels of Literacy?
  • Are you a English Language Learner?

  • Applicant Information:

  • Labor Force Status*
  • Family Demographics*

  • Family Size:

  • Pregnant or Parenting Youth*

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

  • Is your child in your custody*
  • Homeless*
  • Runaway Youth*
  • Public Assistance

  • 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.

  • *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

  • Rows

  • *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

  • 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.

  • Participation Overview, Standards, and Agreement

  • The following opportunities are available to you upon enrollment into the CSPH Youth Program – and your agreement to participate with us to complete the trainings below maximizes your chances of success!

    1. Basic Skills Improvement training (if needed, pending your CASAS results):
      • Increase basic skills in reading and/or math through completion of provided study materials to assist in increasing your skills and increasing your appeal to an employer
      • Complete Post-CASAS testing before exiting the program (if required)
    2. Work Readiness Improvement training (Develop U):
      • Attend assigned workshops, develop a marketable resume, complete mock interview, develop elevator pitch, learn cover application basics and complete financial literacy instruction
      • Complete full Employ Florida registration, including resume and skills, to help with job placement
      • Understand employer needs: what they want and what they expect
    3. Occupational Skills Credential training:
      • Complete at least one industry recognized training credential to help market you to an employer:
        • Customer Service & Sales Certificate
        • Certified Maintenance Employee
        • Food Handler or Manager Certificate
        • Certified Front Desk Representative
        • GED/High School Diploma
        • Certified Restaurant Server
        • Certified Guestroom Attendant
        • Other vocational programs
        • Note: More than one credential may be attained based on funding and individual training needs
    4. Paid Work Experience or Employment Assistance: Job placement assistance including job referrals and/or Work Experience opportunities will be provided once theabove trainings have been completed. There are no guarantees of employment by Youth Program staff and it is acondition of the program for you to actively pursue employment, or engage in a paid Work Experienceassignment that may lead to eventual employment.NOTE: Post-secondary/advanced training may be substituted in lieu of employment.
    5. 14 WIOA Elements: Receive services through the 14 youth elements: tutoring and study skills; alternative secondary school; paid and unpaid
      work experience; occupational skills training; education offered concurrently with workforce preparation; leadership
      development opportunities; supportive services; adult mentoring; follow-up services; comprehensive guidance and
      counseling; financial literacy education; entrepreneurial skills training; services that provide Labor Market information;
      postsecondary preparation and transition activities

    Participant Agreement: As a participant, I understand that the training program I am about to start is paid for with public funds. Due to the nature and scope of information being presented I understand that I will have to try my hardest and follow all program instructions in order to learn and be able to model the skills I will be practicing. Training will include basic educational skills, employability skills, and occupational skills. This is a special program that requires focus, commitment, and my best efforts to maximize my potential success. I understand that this program is a privilege to select youth and no promises will be made by career coaches, and the success of this program will be determined by my actions and the amount of participation that I give. Should any barriers appear, I will bring them to the attention of the Youth Program staff, and try to work through and overcome these obstacles. I assure the Workforce Counselor that I will not drop out of this program and that I know that improving my academic performance is part of this program’s expectations.

    Staff Agreement: CareerSource Pasco Hernando, agrees to provide instruction to our participants in a positive, respectful manner and to provide an environment for open, direct communication. We, as facilitators, will provide them with opportunities to learn enhanced basic skills, employability skills, occupational skills, self-motivation, and self-improvement.

    Program Standards: Participants in the CSPH Youth Program are also expected to meet the following program standards. Failure to do so could result in loss of training or other planned activities.

    1. Be punctual to scheduled activities and appointments
    2. Display appropriate behavior; no abusive language allowed
    3. Maintain good grooming and personal hygiene
    4. Dress appropriately
    5. No use of drugs or alcohol
    6. No weapons of any kind allowed in or around the trainingenvironment
    7. No smoking allowed in unauthorized locations
    8. No telephone calls or texting during activities
    9. No Internet access without permission
    10. Abide by all rules of the facility/business setting

  • Work Experience Incentive Policy

  • Youth may enter a work experience-based learning activity designed to develop skills in their career pathway leading to self-sufficiency. This work experience-based learning opportunity, or “work experience,” consists of six (6) consecutive weeks of work at up to 30 hours per week. Each participant engaged in a work experience may be eligible for an incentive of $100.00. This is limited to one per year. The incentive must be approved by the Workforce Counselor at the completion of the work experience and documentation forwarded to the Program Manager for review and final approval.
    Work Experience Completion Bonus Incentive – ($100)
    To qualify for the incentive, the following must be in adherence throughout your work experience assignment and in accordance to the program rules and regulations:

    1. Must meet 90% satisfactory attendance of the total scheduled hours at the conclusion ofyour work experience assignment. EXAMPLE: agreement with employer set for 6 weeksat 30 hours per week, and per the work schedule on the training plan (180 hours x 90%),a minimum of 162 hours must be completed satisfactorily. Holidays or other acceptableclosure dates to the training site are excluded and will be taken into consideration whencalculating the 90%. The only exception to the 90% hour requirement is if, by the end ofthe agreement, the training site extends an offer of employment, the offer is accepted, andyou begin working successfully as their employee.
    2. Must meet satisfactory work performance and/or improve with progress as indicated bythe site supervisor on your training progress report within the bi-weekly timesheets, and inyour WEX completion survey with required job skills for the position.

    THE MAXIMUM COMBINATION OF PAYMENTS ANY ENROLLED YOUTH MAY EARN FROM THE ECKERD WORKFORCE DEVELOPMENT WEX INCENTIVE PROGRAM IS $100.

    Funding is limited to participants who complete participation requirements during this program year and the availability of State and Federal funding to the Workforce Board.

  • Follow-Up Transition Incentive Policy

  • This policy is for youth during the follow-up period only. This policy requires a commitment to contact and remain in contact with your Workforce Counselor and retention specialist throughout your transition period for one year. If you remain employed or in secondary education/advanced training throughout the 2nd and 4th quarters of follow up you have the opportunity to earn up to $100.00.

    I.Second Quarter - Follow Up Period ($50)
    Incentive payment is contingent upon the completion of the first quarter follow up. Your case must be inactive for 90 days and transition into soft exit. Retention Specialist must complete follow up with verification of your employment or post-secondary education information by contacting your employer or school for verification information or you must provide pay stubs for employment verification in which the dates fall into that follow up period. All assigned tasks must be completed to receive the value of this incentive.


    II.Fourth Quarter - Follow Up Period ($50)
    Incentive payment is contingent upon the completion of the third quarter follow up. You must remain in contact with your Workforce Counselor/retention specialist throughout this transition time. Retention Specialist must complete follow up with verification of your employment or post- secondary education by contacting your employer or school for verification information or you must provide pay stubs for employment verification in which the dates fall into that follow up period. All assigned tasks must be completed to receive the value of this incentive.

    THE MAXIMUM COMBINATION OF PAYMENTS ANY ENROLLED YOUTH MAY EARN FROM THE CAREERSOURCE PASCO HERNANDO WORKFORCE DEVELOPMENT PROGRAM IS $100.


    Funding is available to limited clients who complete participation requirements during this program year and the availability of State and Federal funding to the Workforce Board.

  • Program Consent Form

  • Consent to access School, Law Enforcement and Employment Information
    I authorize CareerSource Pasco Hernando Youth Program to access any school records and test results, law enforcement records, verifications of employment and payroll history as necessary to document eligibility and information for this program. I understand that the information will be used for the sole purpose of documenting eligibility and state-required follow- up for this program.
    Consent for Photography/Videotape Release
    I give my consent to be photographed and/or videotaped in connection with visual documentation of work performed by CareerSource Pasco Hernando Youth Program. I also give permission for any image of likeness to appear in CareerSource Pasco Hernando Youth Program marketing materials including, but not limited to, printed brochures, Internet site, media advertising, Company staff newsletter, and public relations material such as press releases, case studies, and feature articles.

  • Agreement

  • Program Incentive Policy

    Participants are limited to a maximum earning of up to $425 for the program year during program participation. Eckerd Workforce management reserves the right to accept or decline any activity sheets. Youth Program Incentives can be mixed and matched to form a case-specific career plan.
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  • CareerSource Pasco Hernando’s WIOA Youth Program provides opportunities for program participants to earn cash incentives for completing skill-building activities, and obtaining certificates, and getting a job, to be more competitive in the workplace. If a participant completes various educational, employability, or work readiness activities and enters employment, or post-secondary education or an apprenticeship program they will be eligible to earn up to
    $425 in incentives payments.

  • Work Readiness Assessment

    Please be open and honest. This information is between you and your Workforce Counselor only to determine your need for Work Readiness Training. Circle the appropriate answer for each of the following:
  • Do you have a marketable resume?*
  • Do you have a cover letter and thank you letter?*
  • Do you have a full registration in Employ Florida (EF)?*
  • Do you have a professional e-mail?*
  • Do you have any Work Experience?*
  • Do you have any Volunteer Experience?*
  • Do you know how to properly fill out an application?*
  • Do you have an active bank account?*
  • Do you know how to properly communicate with employers?*
  • Are you comfortable in handling conflict on the job?*
  • Do you know how to properly manage your time and stress?*
  • Do you have proper interview attire?*
  • Do you know how to use home computer and internet?*
  • Do you maintain good attendance and show up on time?*
  • Do you know how to use Microsoft Office Word?*

  • Required Document Upload Section

  • To determine eligibility for WIOA Youth services, supporting documents are required. Please upload clear photos or scans of the documents that apply to you. If you do not have a document available, a CareerSource representative will follow up to assist.

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  • Your Social Security Number is encrypted and used only to verify eligibility for WIOA services.
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