Fillable Youth Employment Services Program (YES) Application (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Youth Employment Services Program (YES) Application (Central Council Tlingit and Haida Indian Tribes of Alaska)

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U.S.A. forms for Central Council Tlingit and Haida Indian Tribes of Alaska

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YES Application Page 1
Employment & Training Division
Central Council Tlingit and Haida Indian Tribes of Alaska
320 West Willoughby Avenue, Suite 300
Juneau, Alaska 99801
Phone: 907-463-7392 Fax: 907-463-7392
www.ccthita.org
Youth Employment Services Program (YES) Application
Eligibility:
• Applicants must be 14-21 years of age;
• Applicants must be an enrolled tribal member;
• Applicants must be residing in Southeast Alaska; and
• Applicants must be economically disadvantaged.
For your information, “economically disadvantaged” means:
a) an individual who receives, or is a member of a family that
receives cash welfare payments under a federal, state, or
local welfare program; or b) an individual or a member of a
family whose total family income for the past 30 days
(excluding UI, Child Support Payments, and Welfare
Payments), which in relation to family size, does not exceed
the Poverty Guidelines set forth by the federal government.
Families receiving TANF benefits are eligible for an Income
Waiver. This waiver allows the children of TANF recipients
to work without counting their income towards the total
family income.
Application Requirements:
Complete YES Application;
Written Statement (Page 3);
Tribal Enrollment Card;
Social Security Card;
Identification Documenting Date of Birth;
Proof of Southeast Residency;
Proof of Family Income for the Past 30 Days;
If Applicable, Proof of TANF, APA, UI, SSI;
If Male and 18-21 Years of Age, Proof of
Registering with the Selective Service;
If 14-16 Years of Age, Parent/Guardian Must
Complete Section B on Work Permit Form; and
Complete all hire paperwork: Notice of Hire,
Employment Eligibility Verification and W-4.
YES Information:
Employment and Training administers the Summer Youth
Employment & Training Program (YES), which is designed
to assist tribal youth (ages 14-21) obtain summer
employment. The intent of this program is to enable
participants to become active members in the community by
providing them with employment and training while
encouraging healthy families, education, and leadership.
YES is currently available in 17 Southeast Alaska
communities: Craig, Douglas, Haines, Hoonah, Hydaburg,
Juneau, Kake, Kasaan, Ketchikan, Klawock, Klukwan,
Pelican, Petersburg, Sitka, Skagway, Wrangell, and Yakutat.
Each year, the Juneau YES Coordinator facilitates a Job &
Life Skills Workshop in chosen communities. Sessions
include Job Hunting Tips, Completing an Application,
Writing a Cover Letter, Building a Professional Resume,
Making a Follow-Up Phone Call, Acing the Interview,
Writing a Thank You Letter, Surviving the Job, and the
Power of Choices. It is the Central Council’s goal to share
this information with each YES Coordinator so they can
utilize it in the community year round.
Participants choose to interview for a variety of positions
including clerical work, customer service, manual labor, and
skilled apprenticeships. Over the course of 10 weeks,
participants learn the importance of having an education and
a career, they are challenged to think critically about their
future, and they are encouraged to make good plans and
decisions so they can achieve their potential.
If you have any questions about the application requirements
or should you need any assistance with completing this
application, please contact your local YES Coordinator or
call CCTHITA at 907-463-7171 or 1-800-344-1432 Ext 7171
CENTRAL OFFICE USE ONLY
Applicant Name, Community
Date Application Received
Date Application Reviewed
Complete/Incomplete
Date Completed
Approved/Denied
Reason for Denial
Intake Person’s Initials
Make Selection
YES Application Page 2
CONTACT INFORMATION
First Name
MI
Last Name
Prior First Name
Prior MI
Prior Last Name
Mailing Address
City
State
Zip Code
Physical Address
City
State
Zip Code
Home Phone
Cell Phone
Message Phone
Social Security Number
Date of Birth
Age
Gender
PERMANENT CONTACT
Note: Provide the following information on an individual who does not live with you, but knows how to contact you if you move. It is
important that this person has a telephone.
Full Name
Relationship
Contact Phone Number
PERSONAL DATA
Note: Your response is confidential and in no way prevents you from being eligible for services. If needed, attach a separate sheet of paper.
Marital Status
Single
Married
Separated
Divorced
Widowed
Race/Ethnic Group
Alaska Native
American Indian
Other: ____________________________
Other: ____________________________
Other: ____________________________
Citizenship
US Citizen
Permanent Resident Alien
Refugee/Parolee
Temporary Work Permit
Other: ____________________________
Tribal Enrollment Number
Village/Region/ANSCA Corporation
Questions
Yes
No
Are you a foster child or ward of the state? If Yes, Explain ___________________________________________________________
Are you “at risk” for dropping out of school? If Yes, Explain ___________________________________________________________
Have you completed high school or obtained your GED? If Yes, When and Where ________________________________________
Have you participated in YES in prior years? If Yes, When and Where ________________________________________________
Have you ever been convicted of a felony? If Yes, Explain ___________________________________________________________
Are you currently on probation or parole? If Yes, Name of Probation/Parole Officer ________________________________________
Are you currently under treatment for alcohol/substance abuse? If Yes, When and Where __________________________________
Are you currently being helped by another agency? If Yes, List Agency _________________________________________________
Is it hard for you to read, write, or speak English? If Yes, Explain ______________________________________________________
Do you have a physical or mental disability? If Yes, Explain __________________________________________________________
Are you male and 18-21 years of age? If no, skip forward to the next section.
Have you registered with the Selective Service? If Yes, Registration Number __________________ Date Verified _______________
RELEASE OF INFORMATION
Item(s) Requested
Department Name Information is Being Requested From
I hereby authorize Tlingit & Haida Central Council’s Division of Employment & Training to obtain and exchange information related to my
application to participate in their program(s). I understand that I may revoke this consent by written notice at any time.
________________
_______
________________
_______
a
Applicant Signature
Date
Parent/Guardian Signature (If Applicable)
Date
Female
YES Application Page 3
EDUCATION
Highest Grade Completed (Circle One)
6
7
8
9
10
11
12
13
14
15
16
17+
Middle School
Enrolled in Middle School
Middle School Graduate
High School
Enrolled in High School
High School Graduate
College/Vocational Training
Enrolled in College/Vocational Training
College/Vocational Training Graduate
School Name
School Name
School Name
Date Completed
Date Completed
Date Completed
Type of Degree
GPA
Type of Degree
GPA
Type of Degree
GPA
EMPLOYMENT STATUS
What is your current employment status? Check all that apply.
Employed
Unemployed Seeking Work Full-Time Student
SKILLS AND GOALS
Note: The service you receive will be based largely upon your responses to the questions below. Please answer them as best you can.
List any tools, machinery, and/or equipment you can operate or repair.
List any computer software you can operate.
List any occupational licenses/certificates you have.
How fast can you type?
With how many errors?
List any Volunteer Experience you have done or are currently doing.
List all the extracurricular activities you’ve participated in.
What do you want to do after completing high school and college/vocational school?
What school(s) are you interested in attending?
What will you major in?
Where will you permanently reside upon completing your education?
WRITTEN STATEMENT
In at least 3 complete sentences, describe why you are interested in the Summer Youth Employment & Training Program (YES) and what you would like
to gain by participating in the program. Example topics include: work experience, training, money for personal expenses, etc.
YES Application Page 4
INCOME STATUS
Number of People Residing in Household
Number of Dependants Residing in Household
Place an “X” in the box next to any of the following types of financial support that you or your family members are receiving (MUST provide verification of
each item marked). Family members are persons related to each other by blood, marriage, or adoption, and are living in the same household.
Amount
How Long
Amount
How Long
Supplemental Security Income ____________ ____________ Child Support ____________ ____________
Aide to the Needy Disabled
____________
____________
Survivor’s Benefit
____________
____________
Unemployment Insurance
____________
____________
TANF or ATAP
____________
____________
Alaska Permanent Fund
____________
____________
Food Stamps
____________
____________
Old Age Supplement ____________ ____________ Native Dividend ____________ ____________
Net Rental Income
____________
____________
Alimony
____________
____________
Pension and/or Retirement
____________
____________
Insurance Annuity
____________
____________
Employability Assistance
____________
____________
General Assistance
____________
____________
Adult Public Assistance
____________
____________
Other: _________________
____________
____________
List ALL PERSONS living in the household and their INCOME for the past 30 days or previous month.
Name
Relationship
Date of Birth
Income
Self
Total Income:
SPECIAL NEEDS
Check each item below that applies to you. Explain each checked item on a separate sheet of paper.
Lack of Reliable Transportation
Legal Problems
Trouble with Vision
Inadequate Child Care
Health/Mental Problems
Trouble with Hearing
Lack of Food
Physical Limitations
Trouble Reading/Writing
Lack of Money for Personal Expenses
Lack of Appropriate Work Clothes
Trouble Speaking/Understanding English
Family Problems
Alcohol/Substance Abuse Problems Other: ___________________________
Problems with Child or Children
Pregnancy Needs Other: ___________________________
Inadequate Housing
Dental Care Needs Other: ___________________________
QUESTIONS
Do you have any questions about the Summer Youth Employment & Training Program (YES)? If so, list them here.
$0.00
YES Application Page 5
WORK EXPERIENCE
Note: List your work experience beginning with your most recent job.
Start Date
End Date
Employer/Company Name
Phone Number
Job Title
Address
Immediate Supervisor
Supervisor’s Title
Duties and Responsibilities
Hourly Wage
Reason for Leaving
Start Date
End Date
Employer/Company Name
Phone Number
Job Title
Address
Immediate Supervisor
Supervisor’s Title
Duties and Responsibilities
Hourly Wage
Reason for Leaving
Start Date
End Date
Employer/Company Name
Phone Number
Job Title
Address
Immediate Supervisor
Supervisor’s Title
Duties and Responsibilities
Hourly Wage
Reason for Leaving
APPLICATION CHECKLIST
I completed ALL the blanks on this application.
I turned in my social security card.
I did my written statement on page 3 of the application.
If applicable, I turned in my Selective Service Registration Number.
I turned in my family’s proof of income for the past 30 days.
If applicable, my parent/guardian completed my Work Permit Form.
I turned in my tribal enrollment card.
I completed all hire paperwork: Notice of Hire, I-9, and W-4
I turned in an ID documenting my date of birth.
I reviewed my application to eliminate errors and blanks.
CERTIFICATION
I certify to the best of my knowledge that the information in this application is accurate and true. I understand that my application is subject
to verification, and that falsification of information shall be grounds for termination from the program and may subject me to prosecution
under the law. I understand that there is an Appeal Procedure by which I can challenge a decision made with regard to this application. I
understand my appeal rights and certify that I have read this procedure and that I will abide by it.
________________
_______
________________
_______
a
Applicant Signature
Date
Parent/Guardian Signature (If Applicable)
Date
YES Application Page 6
Employment & Training Division
Central Council Tlingit and Haida Indian Tribes of Alaska
320 West Willoughby Avenue, Suite 300
Juneau, Alaska 99801
Phone: 907-463-7137 Fax: 907-463-7392
www.ccthita.org
Appeal Procedure
An applicant who was denied services or feels he/she may have been treated unfairly, has the right to file a written appeal
(within 15 days after receipt of a decision) by following these procedures:
STEP 1- Program Specialist
An applicant may file a written appeal to the Program Specialist to ask for reconsideration of their decision. The
Program Specialist has 10 working days after the date stamped on the appeal to respond. An applicant not
satisfied with the Program Specialist’s decision may submit their appeal to the Program Manager (Step 2) within
5 days upon receipt of the Program Specialist’s decision.
STEP 2- Program Manager
The Program Manager has 10 working days from the date he/she receives an appeal to review documentation,
make a decision, and respond. An applicant not satisfied with the Program Manager’s decision may resubmit
their appeal to the Appeal Committee (Step 3) within 15 days after receiving the Program Manager’s decision.
STEP 3- Appeal Committee
The Appeal Committee only meets on the 1
st
and 3
rd
Wednesday of each month from 10:00 AM to 12:00 PM to
review appeals. The committee with notify an applicant of their decision within 7 working days after the date of
their meeting. All decisions made by the Appeal Committee are final.
Decisions affecting an applicant are made based on a review of program policies, procedures, and the required
official documents. An applicant has 15 days after receipt of a decision to register an appeal. All decisions made
by the Appeal Committee are final.
YES Application Page 7
Employment & Training Division
Central Council Tlingit and Haida Indian Tribes of Alaska
320 West Willoughby Avenue, Suite 300
Juneau, Alaska 99801
Phone: 907-463-7137 Fax: 907-463-7392
www.ccthita.org
YES Notice of Hire
SECTION ONE
Note: This section should be completed by the YES Participant. Please print clearly.
First Name
MI
Last Name
Prior First Name
Prior MI
Prior Last Name
Mailing Address
City
State
Zip Code
Social Security Number
Date of Birth
Age
Gender
SECTION TWO
Note: This section should be completed by the YES Coordinator. Please print clearly.
Date of Hire
New Hire/Replacement
Replacing Who
Hourly Wage
Job Title
Employer/Company Name
Employer/Company Address
City
State
Zip Code
Immediate Supervisor
Phone Number
Fax Number
SECTION THREE
Note: This section should be completed by Central Office Staff. Please print clearly.
Please submit the following information to the Finance Department.
Copy of Social Security Card
Copy of ID Documenting Date of Birth
W-4 Form
I-9 Form
Central Office Comments
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Account Code: 2000-12- ___ -6006
Female
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Youth Employment Services Program (YES) Application (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Completed 11 August 2020

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