Youth Employment Application for Clearwater, Largo, Lealman, and Tarpon Springs

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

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Phone Number *

Email Address *

Age *

Birthdate *

Gender *Select OneMaleFemalePrefer not to say

PCSB Student ID *

Are you in high school or college? *YesYesNo

What is the highest grade completed? *

Name of school or college *

Credits

Major

Are you attending summer school? *Select oneYesNo

Are you involved in after school activities? *Select oneYesNo

Educational Certifications (check all that apply)MicrosoftInternetCAD / CATPhlebotomy

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

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

Have you ever had a job? *Select oneYesNo

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

How did you hear about this program?

Gross annual household income *

Race (Select One) *ChooseWhiteAsian IndianKoreanNative HawaiianBlack/African AmericanChineseGuamanian or ChamorroSamoanAmerican Indian or Alaska NativeJapaneseVietnameseFilipinoOther AsianOther Pacific IslanderOther RaceMultiracial

Ethnicity (Select One) *ChooseCubanPuerto RicanMexican, Mexican American, ChicanoAnother Hispanic, Latino, or Spanish OriginNot of Hispanic, Latino, or Spanish Origin

Number of adults in household *

Number of children under 18 in household *

Relationship to head of household *Select oneSpouseBrother or SisterSon-in-law or Daughter-in-lawBiological Son or DaughterAdopted Son or DaughterStepson or StepdaughterFather or MotherGrandchildParent-in-lawHousemate or RoommateOther RelativeUnmarried PartnerOther Non-relativeSelf

Household arrangement *Select oneSingle Parent - Female Head of HouseholdSingle Parent - Male Head of HouseholdDual Parent - MarriedDual Parent - Non-married Female Head of HouseholdDual Parent - Non-married Male Head of HouseholdOther Relative/Kinship Care Male Head of HouseholdOther Relative/Kinship Care Female Head of HouseholdOther Relative/Kinship Care - MarriedOther Non-relativeNo Dependent - MarriedNo Dependents - Single FemaleNo Dependents - Single MaleNo Dependents - Couple, Non-Married

Parent/Guardian Name *

Relationship to Applicant *

Parent/Guardian Phone Number *

Parent/Guardian Email Address

Submit

Please do not fill in this field.