Youth Employment Program Form

Youth Employment Program Application

COMPLETION OF THIS DOCUMENT DOES NOT GUARANTEE A POSITION

APPLICANT MUST BE BETWEEN 15 – 21 YEARS OF AGE

THE TOTAL ANNUAL HOUSEHOLD INCOME WILL BE USED TO DETERMINE ELIGIBILITY

INCOMPLETE DOCUMENTS WILL BE DISCARDED

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Phone Number *

Email Address *

Age *

Birthdate *

Gender *

PCSB Student ID *

Are you in high school or college? *

What is the highest grade completed? *

Name of school or college *

Credits

Major

Are you attending summer school? *

Are you involved in after school activities? *

Educational Certifications (check all that apply)MicrosoftInternetCAD / CATPhlebotomy

Do you have a bank account? (Mandatory for direct deposit) *

Do you have a driver's license, learner's permit, or state ID? (Mandatory requirement) *

Have you ever had a job? *

Have you ever been arrested/pending charges? (Background checks mandatory) *

How did you hear about this program?

Gross annual household income *

Race (Select One) *

Ethnicity (Select One) *

Number of adults in household *

Number of children under 18 in household *

Relationship to head of household *

Household arrangement *

Parent/Guardian Name *

Relationship to Applicant *

Parent/Guardian Phone Number *

Parent/Guardian Email Address