Earn & Learn Employer Application

Earn + Learn Work Experience Worksite Master Agreement 2025

Please provide all required details to register your business with us. By completing this form you agree to the program stipulations and requirements throughout this form. Please ensure that you have approximately 15-20 minutes, your clearances, and insurance to fill out this information.
Your Name*

First NameLast Name
Your Role/Title:*
Business Name*
Contact Number*
E-mail*
example@example.com
Please Re-enter E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Agreement Year*
The youth Job Order is attached and becomes part of this agreement. It is agreed that, as a Work Experience Job Worksite/Project, our responsibilities to the Greater Erie Community Action Committee (GECAC) and the work experience job participants will be: 1. To provide meaningful and challenging work experience for youth under our supervision. These assignments should be relevant to the assigned task(s) as stated on the youth job order. 2. To provide adequate supervision by supervisors who are knowledgeable of the Earn + Learn program goals. At a worksite, the supervisory staff will consist of a minimum of one (1) supervisor per (12) participants. Each supervisor must participate in Earn + Learn orientation. 3. To maintain accurate time and attendance records for all participants assigned to the worksite. Participants are paid only for time worked. Participants are not paid for holidays, sick leave, vacation leave, or lunch breaks. 4. To post in a prominent place at the actual worksite, all required Federal and State postings in addition to copies of grievance procedures, anti discrimination, and equal employment opportunity information. 5. To have available on-site emergency phone numbers and contact persons for all participants and to ensure that supervisors are aware of location of emergency listings. 6. To comply with the Federal, State, and Local Child Labor Laws and the Earn + Learn program regulations. 7. To notify the lead agency of any participant problems, pending labor disputes grievances, or any conditions that may affect the performances of this agreement and to immediately report to the Lead Agency all accidents involving any participant. The total number of work experience positions filled during the course of this agreement will be dependent upon (1) the positions available at the worksite offering appropriate and desirable activities for the specific youth available for placement; and (2) the type of work experience that has been identified for the specific youth through their goal planning.
Agreement

The terms of this Master Agreement are contingent upon the receipt of Earn + Learn funds and youth available for placement. This agreement may be terminated at any time if sufficient funds are not received to sustain the length of the agreement or for any reason as determined by Lead Agency or Monitor. This agreement is made and entered into between Greater Erie Community Action Committee (GECAC) and program worksite in ERIE County.
Today's Date:*

MonthDayYear
Name of Worksite Supervisor*

First NameLast Name
Name of Second Worksite Supervisor

First NameLast Name
Signature of Worksite Supervisor*

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Earn + Learn Employer Handbook & Clearances
Handbook
Clearances

You will be asked to upload your clearances. Once obtained, clearances are valid for 5 years. **If you need to obtain your clearances, please obtain them first before continuing the application. For instructions on how to obtain them, please see below.
Current Act 33/34/FBI Clearances are required for any supervisor tasked with supervision of a participating Earn + Learn youth who is 17 years of age or younger. Clearances are not required if the participating youth(s) are 18 years of age or older. All Earn + Learn Employers/Businesses/ Agencies must complete this form regardless of age. If Employers/Business/Agency is unsure of their participants age, please provide clearances, as the majority of participants are 17 years of age or younger.*

I prefer youth 17 years of age or younger (must obtain clearances)I prefer youth 18 years and older only (these youth fall into Tier 2)I do not have an age preference (must obtain clearances)
PLEASE UPLOAD ACT 33/34 CLEARANCE HERE

Complete: OnlineOnline: www.compass.state.pa.us/cwis/public/homeAmount: $13.00 (credit card)Select: Individual 14 years of age or older…..*Print Certificate if result is immediate
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PLEASE UPLOAD ACT 34 CLEARANCE HERE

Complete: OnlineOnline: https://epatch.pa.gov/homeAmount: $22.00 (credit card)Select: - New Record Check- Individual Request- Reason – Employment- Follow rest of the prompts to completeClick on “CERTIFICATE FORM” to print out certificate
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PLEASE UPLOAD FBI CLEARANCE HERE

Online: go to https://www.identogo.com/ Choose: Digital Fingerprinting Pennsylvania Digital Fingerprinting Enter Code: 1KG756 Applicants/employees for all divisions of GECAC. Select: Schedule or Manage Appointment and follow prompts.You will receive an e-mail reminder of the appointment. Be sure to bring the ID information they request. Amount: $28.75
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Insurance

You must have general liability insurance naming GECAC as additionally insured.
Please upload your insurance.

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Earn + Learn Job Description

In previous years, participants in the Earn + Learn program have explored a wide variety of fields and industries, offering valuable opportunities for skill-building and career exploration. In the Arts sector, positions have included roles such as Public Relations Assistant, Art Gallery Assistant, and Media Production. In the Engineering & Industrial Technology pathway, participants have engaged in hands-on roles like Groundskeeping, Housekeeping, Maintenance, Auto Mechanic, Construction, Engineering, Landscaping, Custodial, Warehouse, Manufacturing, and Architecture. For those interested in the Human Services field, roles have included Hostess, Summer Program Activities Aide, Law & Public Safety, Childcare, Visitor/Guest Services, Education, Youth Counselor, Fast Food, Camp Counselor, Cashier, and Restaurant Crew Member. Finally, the Science and Health pathway has provided opportunities in positions such as Animal Care, Physician, Veterinarian Assistant, Farming, Physician Assistant, Nursing, and Dietician. These diverse experiences have helped participants gain practical knowledge and skills in areas that align with their interests and career goals.
How many job positions do you have available?*
Enter a number. * Please note that for every 12 youth there must be 1 supervisor.
Total weekly available hours at this site: *
Enter a number
Participant Job Titles:*
Please list all job positions available.
Who will be the participant(s) Immediate Supervisor:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Who will be the participant(s) secondary supervisor:

First NameLast Name
Phone Number
Please enter a valid phone number.
Is there a dress code or preferred style of dress required of the youth? (i.e. Scrubs, work boots, etc.)*
Where will the youth work?*

InsideOutsideBoth
Please provide a brief job 1- 2 sentence job description here of the general duties the youth will be performing on a day to day basis during their work experience. You will be able to provide a detailed job description next.*
Please attach a more detailed job description specifically listing qualifications, duties, tasks and responsibilities along with any other pertinent job information.*

You may upload more than one.
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Please list any participants that you have identified for placement at your agency / business and Reason.
(Reasonable efforts will be made to accommodate your request.)

Earn + Learn Occupational Privilege Tax Information
To collect the Occupational Privilege Tax from youth employees working at your agency, the following information is needed: Is the Occupational Privilege Tax withheld in the tax district of the worksite*

No. (Any person whose total earned income and net profits from all sources within the political Subdivision is less than $12,000 for anycalendar year in which the tax is levied is exempt from the Payment of the tax for the calendar year)Yes
Name of Tax Municipality:
Payable to:
Address

Street Address

Street Address Line 2

CityState / Province

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

GREATER COMMUNITY ACTION COMMITTEE Earn + Learn BUSINESS ASSOCIATE AGREEMENT

HIPPA PRIVACY COMPLIANCE AGREEMENT FOR BUSINESS ASSOCIATES. This AGREEMENT is made between Greater Erie Community Action Committee (hereinafter known as the "Covered Entity") and the business listed below in the Agency field (hereinafter known as "Business Associate"). Covered Entity and Business Associate shall collectively be known herein as the "the Parties." This agreement replaces any existing like agreement between the Covered Entity and the Business Associate. Whereas, Covered Entity is a provider whose activities may require it to have access to health information; Whereas, Business Associate is in the business of providing services to the Covered Entity and its activities are generally described as consumer services;Whereas, Covered Entity wishes to continue an existing business relationship with Business Associate that has been memorialized in a separate service agreement, which is still in effect;Whereas, the nature of the existing contractual relationship between Covered Entity and Business Associate may involve the exchange of Protected Health Information ("PHI") as that term is defined under the Health Insurance Portability and Accountability Act of 1996 ("HIPPA") as amended by Health Information Technology for Economic and Clinical Health Act of 2009 ("HITECH Act"), including all pertinent regulations issued by the Department of Health and Human Services ("HHS"); The premises having been considered and with acknowledgment of the mutual promises and of other good and valuable consideration herein contained, the Parties, intending to be legally bound, hereby agree as follows: A. Definitions1. Breach - has the same meaning as this term has in § 13402 of Health Information Technology for Economic and Clinical Health Act of 2009 ("HITECH ACT") 2. Business Associate - shall have the meaning given to such term under the Privacy Rule (defined in Section A7 below)and which includes a third party that performs functions for or om behalf of Covered Entity and has access to Covered Entity's PHI and uses such PHI in the performances of its functions 3. Covered Entity - shall mean the Greater Erie Community Action Committee. 4. Designated Record Set - has the same meaning as this term has in 45 CFR § 164.501.5. Electronic Protected Health Information (EPHI) - protected health information that is stored or transmitted by electronic media, as that term is defined by HIPAA Security Rule (including, but not limited to electronic storage media such as computer hard drives, storage or memory disks/cards, and electronic transmission media such as the internet, email, dial-up lines, and physical movement or transport of electronic storage media). 6. Individual - has the same meaning as this term has in 45 CFR § 164.501.7. Privacy Rule - shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 CFR part 160 and Part 164, Subparts A and E, as amended by the HITECH Act.8. Protected Health Information (PHI) - has the same meaning as this term has in 45 CFR § 160.103 (as amended by the HITECH Act), limited to the information created or received by Business Associate from or on behalf of CoveredEntity9. Required By Law - has the same meaning as this term has in 45 CFR § 164.501.10. Secretary - shall mean the Secretary of the U.S. Department of Health and Human Services or his/her designee. 11. Security Rule - means the Security Standards for protection of Electronic Protected Health Information at 45 CFR Part 164, Subpart C, and amendments thereto.12. Unsecured Protected Health Information - shall mean Protected Health Information (PHI) that is not secured through the use of technology or methodology specified by the Secretary in regulations or as otherwise defined in the §13402(h) of the HITECH Act.13. Any prospective amendment to the laws referenced in this definitional section prospectively amends this agreement to incorporate said changes by Congressional act or by regulation of the Secretary of HHS. B. Obligations and Activities of Business Associate 1. Business Associate agrees to not use or disclose Protected Health Information other than as permitted or required by the Agreement or as required by law. 2. Business Associate agrees to employ administrative, physical, and technical safeguards meeting required Security Standards for business associates as required by law to prevent disclosure or use of PHI or EPHI other that as allowed by this agreement. 3. Business Associate agrees to mitigate, to the extent practical, any harmful effect that is known to Business Associate of a use or disclosure of PHI held by Business Associate in violation of the requirement of this agreement. 4. Business Associate agrees to report to Covered Entity any use or disclosure of PHI or EPHI not provided for by this Agreement of which it becomes aware .5. Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides Protected Health Information received from, or created or received by Business Associate on behalf of Covered Entity, agrees to the same restrictions and conditions that apply through this Agreement to Business Associate with respect to PHI and EPHI. 6. Business Associate agrees to document such disclosures of Protected Health Information and information related to such disclosures as would be required for Covered Entity to respond to a request by an Individual for an accounting of disclosures or Protected Health Information in accordance with 45 CFR § 164.528. 7. Business Associate agree to provide to an individual, in a prompt commercially reasonable manner, information collected in accordance with this Agreement, to permit Covered8. Entity to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR § 164.528.9. After the date that Covered Entity informs Business Associate that Covered Entity has implemented an Electronic Health Record, Business Associate shall provide, in response to request from an individual, an accounting of all disclosures the Business Associate made in the past six years of all the individual's PHI.10. Business Associate agrees, at the request of Covered Entity, to provide Covered Entity (or a designated of Covered Entity) access to Protected Health Information in a Designated Record Set in prompt commercially reasonable manner in order to meet the requirements under 45 CFR § 164.524.11. Business Associate agrees to make any amendment(s) to Protected Health Information in a Designated Record Set that the Covered Entity or an Individual, in a prompt and commercially reasonable manner.12. Business Associate agrees to make internal practices, books, and records, including policies and procedures and Protected Health Information, relating to and the use and disclosure of Protected Health Information received from, or created, or received by Business Associated on behalf of, Covered Entity available to the Covered Entity, or to the Secretary (including official representatives of the Secretary), in a prompt commercially reasonable manner for purposes of determining Covered Entity's compliance with the Privacy Rule17.13. Business Associate shall, upon request with reasonable notice, provide Covered Entity access to its premises for are view and demonstration of its internal practices and procedures for safeguarding PHI.14. Business Associate agrees to promptly notify the Covered Entity of any breach of any "unsecured PHI" of the Covered Entity in its possession, but in any event no later than sixty (60) days of the occurrence of the breach as required by Section 13402(b) of the American Recovery and Reinvestment Act of 2009 and any subsequent amendments and resulting regulations.C. Permitted Uses and Disclosures by Business Associate Except as otherwise limited in this Agreement, Business Associate may use or disclose Protected Health Information, as follows: 1. On behalf of, Covered Entity provided that such use or disclosure would not violate the Privacy Rule if done by Covered Entity. 2. Information for the proper management and administration of the Business Associate, provided that disclosure are required by law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and the person notifies the Business Associate of any instance of which it is aware in which the confidentiality of the information has been breached. 3. Business Associate may use PHI to report violations of the law to appropriate Federal and State Authorities consistent with 45 CFR § 164.502(j)(1). 4. Except as otherwise limited in Agreement, Business Associate may use Protected Health Information to provide Data Aggregation to services to Covered Entity as permitted by 45 CFR § 164.504(e)(2)(i)(B).D. Obligations of Covered Entity 1. Covered Entity shall provide Business Associate with a copy of its Notice of Privacy Practices and notify Business Associate of any changes or limitations in its notice of privacy practices pf Covered Entity in accordance with 45 CFT § 164.520, to the extent that such limitation may affect Business Associates use or disclosure of Protected Health Information. 2. Covered Entity shall notify Business Associate of any changes in, or revocation of, permission by Individual to use or disclose Protected Health Information, to the extent that such changes may effect Business Associate's use or disclosure of Protected Health Information.3. Covered Entity shall notify Business Associate of any restrictions to the use or disclosure of Protected Health Information that Covered Entity has agreed to in accordance with 45 CFR § 164.522, to the extent that such restriction may affect Business Associate's use or disclosure of Protected Health Information.4. Covered Entity shall not request Business Associate to use or disclose Protected Health Information in any manner that would not be permissible under the Privacy Rule if done by Covered Entity. Nothing in this paragraph shall restrict the ability of Business Associate to use or disclose PHI as set forth in Section C (Bullet 2).5. Covered Entity will inform Business Associate of any opt-outs exercised by any individual from marketing and/or fundraising activities, to the extent that it knows of any such opt-outs exercised by any individuals from marketing and/or fundraising activities pursuant to 45 CFR § 164.514(e).E. Terms and Termination 1. Terms of Agreement: The Term of this Agreement shall be effective as if the date given at the top of Page 1 herein, and shall terminate when all of the Protected Health Information provided by Covered Entity to Business Associate, or created or received by Business Associate on behalf of Covered Entity , is destroyed or returned to Covered Entity, or, if it is infeasible to return or destroyed Protected Health Information, protections are extended to such information, in accordance with the termination provisions in this Section. 2. Termination for Cause - Upon Covered Entity's knowledge of a material breach by Business Associate, Covered Entity shall either:a) Provide an opportunity for Business Associate to cure the breach or end the violation and terminate this Agreement if Business Associate does not cure the breach or end the violation within the time frame specified by Covered Entity.b) Immediately terminate this Agreement if Business Associate has breached a material term of this Agreement and cure is not possible; or neither termination nor cure is feasible, Covered Entity shall report the violation to the Secretary. 3. Effect of Termination - Except as provided in paragraph E (5) of this section, upon termination of this agreement for any reason, Business Associate shall return or destroy all Protected Health Information received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity. This provision shall apply to Protected Health Information that is in the possession of sub contractors or agents of Business Associate. Business Associate shall retain no copies of the Protected Health Information. 4. In the event that Business Associate determines that returning or destroying the Protected Health Information is infeasible,Business Associate shall provide to Covered Entity notification of the conditions that make return or destruction infeasible. Upon notification to Covered Entity that return or destruction of Protected Health Information is infeasible, Business Associate shall extend the protections of this Agreement to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such Protected Health Information 5. State Law: If state law applicable to the relationship between Business Associate and Covered Entity contains additional or more stringent requirements than federal law for Business Associate regarding any aspect of PHI privacy, then Business Associate agrees to comply with the higher standard contained in applicable state law. 6. Consideration: Business Associate recognizes that the promises it has made in this agreement shall, henceforth, be detrimentally relied upon by Covered Entity in choosing to continue or commence a business relationship with Business Associate.F. Miscellaneous 1. Interpretation - Any ambiguity in this agreement shall be resolved to permit Covered Entity to comply with the Privacy Rule,Security Rule, or HITECH Act.2. Amendment - The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for Covered Entity to comply with the requirements of the Privacy Rules or Security Rule and the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.3. Regulatory References - A reference in this Agreement to a section of the Privacy Rule, Security Rule, or HITECH Act means the section as in effect or as amended.4. Survival - The respective rights and obligations of Business Associate under Section E (3) of this Agreement shall survive the termination of this Agreement.Notice to Covered Entity Any notice required under this Agreement be given to Covered Entity shall be made in writing to:Greater Erie Community Action Committee 18 West 9th Street Erie, PA 16501 Attention: Georgia Del Freo, Vice President of Operations
Agency Name:*
G. Notice to Business Associate

Any Notice required under this Agreement to be given to Business Associate shall be made in writing to:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attention:*

First NameLast Name
COVERED ENTITY: Title: GECAC Chief Executive Officer (Please Leave Blank)

Name __________________________________Date:___________
Business Associate Title*
Your Name*

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Date*

MonthDayYear

Which MANDATORY employer Orientation Date will you be attending?*

In-person May 20th from 9am to 11amVirtual May 20 from 4:30pm to 6:30pm
Which Youth Orientation Date will you be attending?*

June 9th from 11:20am to 1pmJune 10th from 11:20am to 1pm
Should be Empty:

Earn + Learn Work Experience Worksite Master Agreement 2025

Agreement

Earn + Learn Employer Handbook & Clearances

Handbook

Clearances

Insurance

Earn + Learn Job Description

Earn + Learn Occupational Privilege Tax Information

GREATER COMMUNITY ACTION COMMITTEE Earn + Learn BUSINESS ASSOCIATE AGREEMENT

G. Notice to Business Associate