What do we mean by eligible?
Applicants must be Orleans County residents between age 14 and 20 AND
Household income within eligibility range. See chart.
Applicants in foster care or households that receive cash assistance, Medicaid, HEAP, SSI,
and SNAP are automacally eligible
When are applicaons due?
Priority for job placements will be given to applications received by
April 30
th
. Applications received after May 1
St
will be accepted on an
ongoing basis until May 29
th
or until all spots have been filled.
Where do I send my applicaon?
Orleans County Job Development Agency
14016 Route 31 West
Albion, NY 14411
Fax to 585-589-2795
Who do I contact if I have more quesons?
Peter Anderson @ 589-2822 or Peter.Anderson@orleanscountyny.gov
Text: 716-387-4081 Website: orleansny.com/jobdevelopment
Subming a completed applicaon does not guarantee selecon into the program or worksite placement.
What happens next?
If you appear eligible for the program, you will be contacted by the Youth Counselor or a
Program Assistant to set up your interview. If you are under 18 a parent or guardian MUST
sign your applicaon and aend the interview with you.
2020 Summer Youth Employment Program
(SYEP) Application
Orleans County Job Development Agency
Family
Size
Yearly
Income
1
$25,520
2
$34,480
3
$43,440
4
$52,400
5
$61,360
6
$70,320
7
$79,280
8
$88,240
A proud partner of the
Network
Orleans County Job Development Agency
Summer Youth Employment Program (SYEP)
List of Documents Required for Eligibility Interview
**Any applicant under 18 years old must have a parent/guardian aend the interview
1. Income Documents You need to check one of these boxes
You are automacally income eligible if you get cash assistance, SNAP, Medicaid, HEAP, SSI or if in
foster care. Please provide award leer as proof.
OR
If you dont have any of the above, you will need proof of all family members income for the past 26 weeks
(6 months). That can include:
Employment – most recent paycheck (stub) with year to date total
Copy of social security check, award leer, or bank statement showing deposit
Rerement income statement, check, or bank statement
Unemployment Insurance – determinaon leer or payment history print out
Copy of child support and/or alimony check, a signed note from paying parent that states the total
amount or form from Support Collecon Unit
Statement of Self-Employment income showing income and expenses
AND
2. Idencaon and cizenship documents –items below:
Orleans Youth Employment Program
Initial Assessment
Applicant Name: ____________________________________
Race White Black or African American Hispanic or Latino
Alaskan/American Indian Asian Hawaiian/Pacific Islander Other
Note: Ethnicity question is voluntary. Information will be kept confidential and is intended for use solely in connection with rec-
ord keeping and affirmative action requirements. You will not be penalized for refusal to answer.
Have you ever been convicted of a crime? Yes No
If yes, explain in full: _______________________________________________________________________________________________
Males-18 years and older, are you registered for Selective Service? Yes No If no, register at sss.gov
EDUCATION:
High School _____________________________ Grade ____ Do you have IEP 504 AIS Vocational program _________________________
Earned a high school diploma or equivalency diploma? Yes No
SKILLS and INTERESTS
List your skills and abilities you have learned in a job, at home, as a chore, or as a hobby.
____________________________________________________________________________________________________________________
List your volunteer and/or community service performed: _______________________________________________________________
Which type of worksite do you prefer?
Office Retail Assembly and Production Recreation Program
Outdoor Maintenance Food Service Day Care Center Center for Disabled Adults/Youth
Indoor Maintenance Nursing Home Hospitality Other ___________________
CAREER INTEREST:
Which of the following high demand jobs are you interested in learning more about?
Advanced Manufacturing: HVAC Welding Optics Machining Auto Mechanic
Health Care: Home Health Aide (HHA) Certified Nursing Aide (CNA) Licensed Practical Nurse (LPN) Registered Nurse (RN)
Agriculture Truck Driving Starting your own business
If you could have a job right now, what would it be? _____________________________________________________________________________
What job do you want 5 years from now? __________________________Why? _______________________________________________________
TRANSPORTATION: How will you get to a job or appointment? Bicycle Parents Own Car Public Transportation Walk
Do you have a driver’s license? Yes No If No, do you have a Learner’s Permit? Yes No
WORK HISTORY: ( See Attached Resume)
Job Title _____________________________________ Employer _________________________________________________
Address ___________________________________________________________________
Wage $__________________
City __________________________________________
State ________ Country, if not US ______________________
Start Date _____/_____/_____ End Date __/__/___
Reason for leaving _____________________________________
Job Duties __________________________________________________________________________________________________________
YOUTH EMPLOYMENT PROGRAM
Agency Release of Information Form
I / we hereby authorize the release of information to or by the Orleans County Job Development Agency
with the agencies listed below in order to determine eligibility and to provide complete and proper Case
Management Services. I / we understand that the release will allow communications at needed intervals.
I / we understand that this release will be updated annually and may be revoked by me at any time with
written notification. Also, I / we understand that I / we may cross out any agency that I / we do not wish to
share information with the Orleans County Job Development Agency.
AGENCIES
_______________________________________ _____________________________________
Applicants Name PRINTED Applicants Name SIGNED
_______________________________________________________________ __________________
Parent/Guardian Signature (If applicant is UNDER 18 years old) DATE
PHOTO RELEASE
I / We give permission for my photo to be taken at work experience, field trips, and workshops or in other
activities sponsored by the Orleans County Job Development Agency as part of the Youth Employment
Program. These photos may be published in the newspaper, posted or used in reports and publications /
website of the department or of the GLOW Workforce Investment Board and I may not receive monetary
compensation.
_______________________________________ _____________________________________
Applicants Name PRINTED Applicants Name SIGNED
_______________________________________________________________ __________________
Parent/Guardian Signature (If applicant is UNDER 18 years old) DATE
 Applicants School District  Orleans Niagara BOCES
 Orleans County Mental Health  Orleans County Sheriffs Office & Jail
 Orleans County Probation  Orleans County Youth Bureau
 NYS One Stop Operating System Database  Catholic Charities of Tri-Counties
 NYS Department of Labor  Mobile Mental Health team
 NYS Career Zone  GCASA
 Orleans County Dept. of Social Services  ACCESS/VR
 Orleans County Dept. of Health  Upward Bound
 GED/TASC Class  Orleans County Sheriffs office and Jail
 Applicants Worksite and the Supervisor  College youth may be attending
 Literacy Volunteers of Genesee/Orleans County  Other _____________________________
County of Orleans
Job Development Agency
14016 Route 31 West
Albion, NY 14411
585-589-7000
585-589-2795 Fax
click to sign
signature
click to edit
click to sign
signature
click to edit
I, _____________________________________________________
(PRINT NAME OF PARTICIPANT)
Agree to participate in the total Youth Job Development Employment Program and under-
stand that the purpose of the program is to help me develop the skills I will need to succeed
in school and work.
As a participant, I will:
1. Respect myself, my co-workers, supervisors, and Job Development staff.
2. Have perfect attendance for work and/or classroom activities.
3. Arrange for my own transportation to and from classroom activities and my work-
place.
4. Wear appropriate clothing to pre-employment, employment and classroom activi-
ties.
5. Understand that, prior to starting my work assignment, I will need to complete an
application, attend an interview/ eligibility appointment, and attend an orientation.
6. Bring a legible copy of my birth certificate, social security card, and picture ID to my
eligibility appointment and proof of income if necessary.
7. Understand that there will be mandatory enrichment classroom activities that I will
need to attend and complete before my work assignment can start.
8. Understand that my signature on this document constitutes an agreement between
me and the Orleans County Job Development Agency.
9. Understand that I, my employer or my education provider may be contacted during
and up to one year from my active enrollment in the Orleans County Youth Employ-
ment Program to gather information regarding the terms and conditions of my em-
ployment and work status.
Participant Signature: ______________________________________________________
Parent/Guardian Signature: _________________________________________________
Date: _______________________
County of Orleans
Job Development Agency
14016 Route 31 West
Albion, NY 14411
585-589-7000
585-589-2795 Fax
click to sign
signature
click to edit
click to sign
signature
click to edit
ORLEANS COUNTY JOB DEVELOPMENT AGENCY
MEDICAL HISTORY QUESTIONNAIRE
DIRECTIONS This quesonnaire must be completed and signed by a parent or guardian prior to
enrollment into the Youth Employment Program of the individual listed below. Failure to return this
completed form to the Orleans County Job Development Agency oce will delay the start of your
childs/dependents employment assignment. Thank you for your cooperaon.
Has your child/dependent ever been treated for or had symptoms of the following:
YES NO YES NO
Heart Problems _____ _____ Dizziness/Fainng _____ _____
Breathing Problems _____ _____ High Blood Pressure _____ _____
Tuberculosis _____ _____ Frequent Headaches _____ _____
Head/Neck Injuries _____ _____ Vision Problems _____ _____
Hernia _____ _____ Epilepsy _____ _____
Back Injuries _____ _____ Skin Disorders _____ _____
Rheumac Fever _____ _____ Nervous System Disorder _____ _____
Scarlet Fever _____ _____ Frequent Colds/Sore Throat _____ _____
Anemia _____ _____ Hearing Loss _____ _____
Asthma or Allergies _____ _____ Alcoholism/Drug Addicon _____ _____
Diabetes _____ _____
Has your child/dependent ever had an operaon? YES_____ NO_____
If yes, please explain and supply dates: ___________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Has your child/dependent ever suered a previous injury? YES_____ NO______
If yes, please describe the nature of injury and list dates: _____________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
PARTICIPANTS NAME ___________________________________________________
Date of last physical ________________Primary Care
Physician______________________________________
Is your child/dependent covered by health insurance? Yes _____ No _____
If yes, who is the subscriber , the name of the insurance and the contract#
____________________________________________________________
Is your child/dependent taking prescripon drugs? _____Yes ______No
If yes, please list medicaons and any special instrucons if the need to be administered during work
hours.____________________________________________________________________________________
_________________________________________________________________________________________
Are there any known physical, mental or medical problems which would prevent or limit your child/dependent
from work in our Youth Employment Program? _____Yes ______No
If yes, please describe and explain what accommodaons would be necessary:__________________________
___________________________________________________________________________________________
Do you give your permission to have medical assistance provided either at the worksite or at a hospital, should
your child/dependent need medical aenon at their worksite? _____Yes ______No
Please provide contact numbers you can be reached at during the workday in the event of an emergency.
______________________________________ ______________________________________________
Mother/Guardian Name Father/Guardian Name
_______________________ ______________ ______________________ _______________________
Home Phone Work Phone Home Phone Work Phone
______________________________________ _______________________________________________
Cell Phone Cell Phone
IF A PARENT/GUARDIAN IS UNABLE TO BE REACHED, CONTACT:
______________________________________ ____________________________________________
Name & Relaonship Name & Relaonship
___________________ ______________ _____________________ _________________
Home Phone Work Phone Home Phone Work Phone
______________________________________ __________________________________________
Cell Phone Cell Phone
My signature below ceres that all informaon provided is true and correct to the best of my knowledge. I give
my permission for my child/dependent to be treated for illness/injury sustained in connecon with their parci-
paon as a Youth Employee for the Orleans County Job Development Agency. I also give permission for my child/
dependent to be transported by a counselor, worksite supervisor, or a Job Development Agency sta member, or
ambulance in the event of an emergency.
Sign here: __________________________________ _______________________
Parent or Guardian Signature Date
Medical 2018
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