APPLICATION INSTRUCTIONS *APPLICATION DEADLINE: April 15, 2015 Dear Students, Parents and Legal Guardians: Welcome to Madison Park Development Corporation’s Soheil Turner Youth Leadership Institute (STYLI), 2015 Summer Youth Employment Program (SYEP). Our program provides underserved in-school youth, ages 14-19, with summer job placement, job readiness skills, and educational enrichment. Our training program is intended to provide early workforce experience for young people who might not otherwise have this opportunity, while supporting them with completing academic summer assignments to start their next academic school year. We also provide organized workshops and learning experiences to develop young people’s leadership skills. In order to be eligible for MPDC’s 2015 SYEP youth must be available to work from July 6, 2015 to August 21, 2015. Please note that completing this application does not guarantee a work assignment. Please read the application guidelines carefully before submitting the application. Please print clearly in ink. Answer each question carefully and do not leave any black spaces. Incomplete applications will not be accepted. If you have questions about completing this application please email Kevin Wilkerson at kwilkerson@madison-park.org or Erica Davis edavis@madison-park.org. This application is also available online at www.madison-park.org. 1. A valid copy of your social security card is required to participate in the program. Please attach a signed copy of your social security card to this application. If you do not have a social security card, you must apply for a card at 10 Malcolm X Blvd, Roxbury, MA 02119. Hours: Mon-Tues., Thurs.-Fri. 9am-3pm and Wed. 9am-12pm. For more info please call 1 (800) 772-1213 or go to www.ssa.gov. You must obtain a document from Social Security stating that you have applied for a card. Your application will be considered incomplete until we receive a copy of your official card. 2. Please attach a copy of your birth certificate, or other proof of age (i.e., driver’s license, state issued I.D.) 3. Please attach a copy of your most recent report card. Grades will not determine eligibility, but are for in-school verification and evaluation purposes only. 4. Please complete and attach Forms MA W-9 (2015) http://www.irs.gov/pub/irs-pdf/fw9.pdf and Employment Permit Application (2015) http://www.mass.gov/lwd/docs/dos/youth-employment/youth-application.pdf. All information provided will be kept confidential and used only for the purposes of facilitating employment opportunities. Thank you, Kevin Wilkerson, Youth Program Coordinator Erica Davis, Youth Leadership & Workforce Development Organizer Last Name: Address: Home Phone: First Name: City: Middle: State: Cell Phone: Zip: Date of Birth: Email: Shirt Size: Social Security Number: Do you have Health Insurance? Yes Gender: Female No Who is your Provider? Parent/Guardian Name: Telephone: Email: Is English your primary (or first) language? Yes No If no, what language? Male Emergency Contact Name: Phone Number: Relationship: Race/Ethnicity: (please check one) American Indian Alaskan Native Black/African-American Asian/ Pacific Islander Hispanic/ Latino White Other:______________________________ Have you ever been employed by MPDC? Yes School Name: Previous employer: Dates of employment: Title: Duties: Grade: No If so, when? Year of Graduation: Work Availability: Please fill out as accurately as possible. Monday Tuesday Wednesday Thursday Friday 1.) Have you ever been in a position where you had to work as a team? Provide an example of when you had to work as a team. 2.) Do you have any skills that will help us? List some of the skills. 3.) What would you consider some of your strengths? 4.) What are some of your weaknesses? How can we help you improve? 5.) Why do you think youth jobs are important? 6.) How do you feel about School? 7.) What is your favorite subject in school? 8.) If you could get tutoring, what subject would it be and why? What type of job opportunities are you interested in? * (Please select up to three (3) areas of interests from the list below.) Administrative / Office Assistants Art (Painting / Drawing /Graphic Design) Camp Counselor Community Organizing Custodial Work / Maintenance Day Care / Teacher's Assistant Environmental / Landscaping Government / Public Service Health Care Communications / Media / Journalism Recreation and Sports Other: By typing name below, you agree to the following terms: • I understand that youth employees in the 2015 Summer Employment Program that provide a service to anyone 18 years or under or the elderly, MUST have a Criminal Offender Record Information (CORI) and Sexual Offender Record Information (SORI) background check conducted. • I confirm that, to my knowledge, the information provided in the application above is accurate. Also, by typing my name in the box below, I am providing my electronic-signature to submit the application. Applicant Signature (Please Write Your Full Name): ________________________________________