cra summer youth training institute · 2013-09-10 · cra summer youth training institute . south...

OVERTOWN ADDRESS VERFICATION

- School Printout - Utility Bill with Caregiver/Parent Name - Copy of State Identification RECOMMENDATION - A letter of recommendation by an adult (optional)

APPLICATION & OTHER DOCUMENTATION - Complete Intern Application - Copy of State Issued Identification or Passport - Copy of Birth Certificate - Copy of Social Security Card or Green Card - Most Recent Report Card - Resume - Parent/Caregiver Permission and Release Form

FOR COLLEGE STUDENTS - Paid Summer Internship Opportunity - Most Recent Transcript or College Acceptance Letter - Submit Resume & Cover Letter - Complete Internship Application - Copy of State Id and Social Security Card - Recommendation (optional) *Select # of slots may be available for youth residing outside of Overtown, but within City of Miami District 5 boundaries. Restrictions do apply.

CRA SUMMER YOUTH TRAINING INSTITUTE

S O U T H E A S T O V E R T O W N P A R K W E S T ( S E O P W ) C O M M U N I T Y R E D E V E L O P M E N T A G E N C Y

Are you between the ages of

15-24? Are you interested in:

- Video Production - Starting a Business

- Arts & Culture

- Earning a Training Stipend

Then this opportunity may be for you!

APPLICATIONS AVAILABLE AT www.urgentinc.org

ONLY 50 SPACES

APPLY EARLY!

APPLICATIONS DUE NO LATER THAN

July 2, 2013

Return Complete Applications to URGENT, Inc.

1000 NW 1st Ave. Suite 100 Miami, FL 33136

305-205-4605

W W W. U R G E N T I N C . O R G 1000 NW 1st Ave. Miami, FL 33136 Tel 786-439-1544 Fax 866-811-7778 Email: [email protected]

E L G I B I L I T Y R E Q U I R E M E N T S

Form 7-5 1

URGENT INC. YOUTH INTERNSHIP APPLICATION

URGENT, Inc. (the "Company") is an equal opportunity/affirmative action employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, or physical or mental disability.

PERSONAL

Last Name First Initial

Social Security #

Other Name(s) Used

DOB:

Address City, FL Zip

Cell Phone # Accept Text Yes No

Alternate #

Facebook:______________________ Twitter: @ _____________________

Email:

Position Applied For:

Referred By:

Hourly Rate Desired:

Are you at least 15 years old?

Yes No

If under 18, Parent Name:

EDUCATION

Circle Highest Grade/Year Completed: High School 9 10 11 12

College 1 2 3 4

School

Name City, ST

Major Studies Or Academy/Magnet

Degree, Diploma,

License or Certificate College/University

Year Anticipated ________ Type: ________________

High School

Year Anticipated ________ Year Obtained ________

Vocational, Business, Other

List Any Trainings Attended, Clubs or Organizations to which you belong: Other Special Knowledge, Skills or Talents

Form 7-5 2

Do you type? Yes No If yes, WPM: Computer Skills: Microsoft Word Power Point Excel Access Publisher Internet Email Other__________________________________________ What are your post high school plans (If applicable) Job 2 year College Associates Degree 4 year College/University Apprenticeship Military Branch______________ Don’t Know Yet What is your long term career goal? Training Institute Preference:

Arts & Culture: Visual Arts Travel/Tourism

Film/Video Production: Behind the Scenes In front of the Camera Music

Entrepreneurship/Business

Hospitality/Customer Service

Availability:

Monday Tuesday Wednesday Thursday Friday

Soonest Start Date:______________ Last Date Available:______________________

Do you have to attend Summer School? Yes No

Do you to participate in Virtual School? Yes No

EMPLOYMENT/VOLUNTEER HISTORY List all employment or volunteer experience for the past 4 years, starting with the most recent position. All information must be completed. However you may attach a resume, but not in place of completing the required information. (Information on resume does not have to be repeated) Employed From

Employer Name

Supervisor Name

Starting Salary

Employed Until

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

Form 7-5 3

Employed From

Employer Name

Supervisor Name

Starting Salary

Employed Until

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving


Employed From

Employer Name

Supervisor Name

Starting Salary

Employed Until

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving


GENERAL

Yes No

May we contact your current employer for references?

If hired, will you be able to work evenings and weekends?

Will you be able to perform the essential job functions for the position you are

applying for with or without reasonable supervision? Have you ever been convicted of a crime, excluding misdemeanors and summary

offenses, which has not been annulled, expunged or seals by court? (A yes response does not automatically disqualify your application.)

Will you submit for a background screening? CERTIFICATION & AUTHORIZATION

The above information is true and correct. I understand that, in the event of my employment by the Company, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.

Form 7-5 4

I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize the Company to obtain a criminal and driver background check. I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Company is intended to create an employment contract between myself and the Company under which my employment could be terminated only for cause. On the contrary I understand and agree that, if hired, my employment will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form I-9. I hereby acknowledge that I have read and agree to the above statements.

Applicant Signature Date

Parent Signature (If under 18) Date

Modified SN: Orginal Copyright ©1999 by Richard D. Harroch. All Rights Reserved.

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1000 NW 1st Ave. STE 100 Miami, FL 33136 786-439-1544(O) 866.811.7778(F)

[email protected] www.urgentinc.org

“Empowering Young Minds to Transform Their Communities”

Pre-Interview Questions

1. If your life was a movie, what would be the title and tagline be?

2. In four sentences, tell us about yourself.

3. Write down as many different uses as you can think of for the following items: a brick, a blanket

BRICK BLANKET

4. Describe how the brick/blanket question is relevant to the work we do with youth.

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5. Complete the work place values worksheet by following the stated directions. a. Identify your top seven values for both the top and bottom sections. b. Prioritize each set from 1 to 7 (1= most important) c. Write your work mission and purpose statement using each set of values.

i. Begin the first statement with, “My purpose is….” ii. Begin the second statement with, “In order to carry out my purpose, I will….”

©2005 Emily Diane Gunter

WHAT ARE YOUR WORK VALUES

Values are essential because they define the ideal purpose or character of your career. Purpose Work Values describe WHAT you want to do. Operational Work Values describe HOW you will focus your thoughts to get to where you want to go.

PURPOSE WORK VALUES- You have a commitment to bring WHAT to the Organization?Achievement - accomplishment of identified goals and objectives 1. ______________________________Community - a concern for the organization’s impact on the community 2. _______________________________Contentment – joyfully satisfied, fortunate and willing 3. _______________________________Contribution - giving, aiding and assisting 4. _______________________________Drive – pro-active, industrious, goal directed 5. _______________________________Efficiency – effectively producing the most with the least resources 6. _______________________________Equality – unbiased treatment for all, regardless of rank, ethnicity or gender 7.______________________________Excellence – having a high standard of quality, striving to be the best 8.________________________________Empowerment –allowing every member to make valuable contributions 9.________________________________Fellowship – having valued trusted relationships, camaraderie 10._______________________________Growth – development, evolution, improvement and change 11._______________________________Harmony – agreement, concurrence, consensus and unison 12. _______________________________Humility – modest, unoffended, confident, calm, moderate and reserve 13. _______________________________Innovation – change, freshness, variation and invention 14._______________________________Integrity – honor, honesty, wholeness, truth and respect 15. _______________________________Leadership – influence, guidance and direction with purpose 16. _______________________________Learning – acquiring of knowledge and skill 17. _______________________________Responsibility – accountability, reliability and authority to act from within 18. _______________________________Safety – an environment free from fear, danger, harm and injury 19. _______________________________Service - total customer satisfaction-eternally & externally 20. _______________________________Teamwork – cooperative effort, collaborative endeavor and participation 21. ______________________________

OPERATIONAL WORK VALUES-How will you obtain your purpose?Accountability - responsibility, credibility and trustworthiness 1. ______________________________Compassion – kindness, mercy, heart, understanding with sincere rapport 2. ______________________________Communication – actively listening first when exchanging information 3. ______________________________Cooperation – alliance, affiliation, common ground and working together 4. _____________________________Counseling - mentoring, coaching, advising, guiding and suggesting 5. ______________________________Courage – confident, firm, ability to face uncertainty without fear 6. _____________________________Creativity – inventive original, conceive and design a future possibility 7. ______________________________Dependability – reliability, commitment, soundness and consistency 8._______________________________Diversity - understanding and managing differences, multiplicity 9._______________________________Discipline – highly trained and focused on objectives, constructive correction 10._____________________________Drive – highly motivated to get the job done 11._______________________________Education – learning, training, instruction and preparation 12. ______________________________Fairness – consistent just and impartial decision making 13. ______________________________Flexibility – ability to change and adapt to new situations 14._______________________________Independence – autonomy, self-reliant, self-directed, initiative 15. ______________________________Knowledge – making effective use of information 16. ______________________________Mutual Admiration – recognition and appreciation of others’ geniuses 17. _____________________________Patience – to persevere calmly when faced with difficulty 18. _____________________________Recognition – acknowledging important contributions 19. ______________________________Versatility – resourcefulness, ingenuity, moving easily between tasks 20._______________________________Win-Win – mutual success and gain for all involved 21. ______________________________

1 | P a g e

PersonalAssetsQuestionnaire1. Name:

2. Email:

3. Affiliation:

4. Address:

5. What roles do you have in the the community?

a. Professional-

b. Personal-

c. Leadership-

d. Network(s)-

e. Resources-

6. Identify two of your personal talents

a.

b.

7. Indentify two of your learned skills

a.

b.

8. Identify two hopes or aspirations for your community

c.

d.

9. Identify two positive things everyone should know about your community

10.

11.

URGENT,INC.WORK/VOLUNTEER AVAILIBILITY

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

8:00

9:00

10:00

11:00

Noon

1:00

2:00

3:00

4:005:00

6:00

7:00

*Please indicate your daily availability

Youth's Last Name______________________, First ____________________

URGENT, INC. 1000 NW 1st Ave. STE 100 Miami, FL 33136 l 786-439-1544 ph l 866-811-7778 fax l [email protected] l www.urgentinc.org

Revised 3/2013 SN

PROGRAM ENROLLMENT APPLICATION (Part I- YOUTH)

PROGRAM: After School Summer Camp Rites of Passage Intergenerational Youth Training

Last___________________First_____________

Youth's Date of Birth (00/00/000)

Age:

If your youth is age six or younger has your youth completed pre-kindergarten? Yes No

Gender Male Female

Last 4 Digits ONLY of Youth's Social Security#

No SSN Prefer not to give

Miami-Dade County Public School ID#

No MDCPS ID

Prefer not to give

Current School ___________________________

Is Youth Proficient in English? Yes No Other Language(s) Spoken in the Home

Spanish Haitian-Creole Other_____________ None

Street Address_________________________

Apt# ______City ___________ ZIP__________

Youth’s Cell Phone(if applicable):

______-______-__________ Smart Phone

Accept Text messages: Yes No

Youth’s Email:_________________________

Ethnicity Hispanic Haitian Other________

Youth's Race American Indian or Alaskan Asian Black or African American

Pacific Islander White Other_______

Access to Home Computer: Yes No

Access to Home Internet: Yes No

What Grade is your youth in now?

Highest Grade youth has completed?

Does youth receive? Free School Lunch Reduced School Lunch N/A

Youth T-Shirt Size? Adult S M L XL

Does Youth Have Health Insurance? Private Insurance Kidcare Medicaid Other___________ No Insurance

If no, we may be able to help you find affordable coverage-call 211 or visit www.thechildrenstrust.org

Does Your Youth Have any documents below?

(check all that apply) : N/A

Individualized Family Service Plan

Individualized Education Plan (IEP)

Section 504 Plan

Medical Diagnoses from a doctor

Diagnosis by a state certified/licensed professional

I attest that my youth has a specific condition that may need special accommodations:_____________

Does your youth have any of the conditions identified below? (check all that apply)

Autism Spectrum Disorder Asthma

Sun Exposure Sensitivity dairy Diabetes

Emotional/Behavioral Disorder Nose Bleeds

Developmental Delay (if under 5)

Hearing Impairment/deaf

Impairment: Speech Language Vision

Disability: Physical Intellectual Learning

Allergy: Nuts Bee Dairy Grass Fruit

Chronic Medical Condition:__________________

Medication: Yes At Home As Needed

#1-Youth's Last Name______________________, First ____________________




Revised 3/2013 SN

PROGRAM ENROLLMENT APPLICATION (Part II-PARENT/CAREGIVER) PROGRAM: After School Summer Camp Rites of Passage Intergenerational Other_________

Parent/Caregiver (1) Parent/Caregiver (2)

Parent Caregiver Guardian

Last Name ___ , First _

Date of Birth (mo/day/0000)

Age

Gender Male Female

Are You Proficient in English? Yes No

Street Address ____

City _ ZIP Code _

Youth lives at this address Yes No

Ethnicity Hispanic Haitian Other, please specify:

Race American Indian or Alaskan Asian

Black or African American Pacific Islander

White Other, please specify:

What is the Highest Education You Completed?

Grade HS Diploma/GED

Some College Associate’s Degree

Bachelor’s Degree Graduate Degree

How many children are in your care? ________

Primary Phone Number Type: C WK HM ______-______-________

If cell, Do you accept text messages: Yes No

Alternate PH ______-______-________

Email: __

Facebook: Twitter: @

Parent Caregiver Guardian

Last Name ___ , First _

Date of Birth (mo/day/0000)

Age

Gender Male Female

Are You Proficient in English? Yes No

Street Address ____

City _ ZIP Code _

Youth lives at this address Yes No

Ethnicity Hispanic Haitian Other

Race American Indian or Alaskan Asian

Black or African American Pacific Islander

White Other:

What is the Highest Education Completed?

Grade HS Diploma/GED

Some College Associate’s Degree

Bachelor’s Degree Graduate Degree

Is this person authorized to pick-up your youth from the program? Yes No

Primary Phone Number Type: C WK HM ______-______-______ If cell, Do you accept text messages: Yes No

Alternate PH ______-______-________

Email: __

Facebook:

Twitter: @





Revised 3/2013 SN

Number of Children Living in the Household, including youth participant(s): Family Type: Military Foster Family Migrant 1st Generation Immigrant N/A

Other language(s) spoken in the home Spanish Haitian-Creole Other:__________ None

Head of Household Type: Single Parent 2 Parent Grandparent/Relative Family Size:

Annual Income: Less Than $13,750 $22,990 $36,650 More Than $36,650

Source: Social Security/Disability TANF/SNAP Work Employer:

#1—Emergency/Alternate Contact

Last Name ___ , First _ Relationship _____

Phone Number ______-______-________

Is this: Cell Work Home


#2—Emergency/Alternate Contact

Last Name , First Relationship

Phone Number ______-______-________ Is this: Cell Work Home


Has your youth attended an Urgent, Inc. program before? Yes No

If yes, How long?____ What Program? Summer After School Rites of Passage Other______

How did you hear about this program? Email Friend/Family Word of Mouth Other_______

Do you have family members that attend or have attended this program? Yes No

If yes, who:

If you are interested in other services funded by The Children’s Trust, call 211 or visit www.thechildrenstrust.org I give my permission for my youth/self to participate in URGENT, Inc.’s program. I understand funding for this program may be supported by The Children’s Trust, Miami-Dade County and City of Miami. I understand that my information will be submitted to these funders for program monitoring and evaluation purposes. I also understand I may be contacted by one of these agencies for quality improvement purposes. I hereby certify that my youth and myself are fully capable of participating in this program. PARENT/CAREGIVER SIGNATURE __________________________________ DATE______________ FOR STAFF USE ONLY (MUST BE COMPLETED) ORGANIZATION: URGENT, INC. SITE LOCATION: BTW MEM Goulds EPE UM Other_______ PRIORITY POPULATION MEMBERSHIP: Migr Farm Wrk Dep Syst Delin Syst Homeless/Transitional

Youth : Last Name ___ , First ________ __

URGENT, INC. l 1000 NW 1ST AVE. STE 100 MIAMI, FL 33136 l 786-439-1544PH [email protected] l WWW.URGENTINC.ORG

URGENT, INC. PARTICIPANT AGREEMENT AND LIABILITY RELEASE FORM Note: By initialing below, you acknowledge that you have read and agree to each item.

_____ [Initial] LIABILITY RELEASE We the undersigned parent and/or guardian and participant agree that in consideration of our participation, we, parent and/or guardian and participant, jointly and severally, and intending to legally bind ourselves, our hearts, executors and administrators, do hereby waive, release and discharge Urgent, Inc., all Urgent, Inc. sponsors, contractors, members, staff, volunteers, supervisors, and instructors, or supervising or sponsoring organizations and all of the members, agents, employees, representatives, successors, and assigns from any and all liability and/or claims for illness, injury, and damages that may arise directly or indirectly as a result of participation in any Urgent, Inc. event, or of participant’s travel to and /or from event venues. _____ [Initial] MEDICAL VERIFICATION AND CONSENT We, Parent and/or guardian and participant, attest that the applicant is physically able to participate in all activities planned and hosted by Urgent, Inc. and that the participant’s physical condition has been verified by a licensed medical doctor. We also consent to any needed medical treatment or transportation for the participant and/or self in the event of an emergency. I hereby give my permission to the physician to secure and administer treatment, including authorization for my child named above.

Insurance Company: Policy Number:

Name of Child’s Doctor: Phone:

_____ [Initial] TRANSPORTATION AND FIELD TRIP CONSENT We the undersigned parent and/or guardian and participant agree that in consideration of our participation my family has permission to be transported by URGENT staff by bus, van, or car—depending on routing and pick-up/drop-off schedules. I consider my child(ren) responsible in following rules, staying with the group, and using common safety precautions during each event. I further agree to direct them to follow the safety instructions given by the staff in charge. If my child(ren) depart from the event premise without permission, I do not consider URGENT liable and I expect to receive an immediate phone call to the number on file. I further understand that my child(ren) will be returned to either their home address, or to the original place they were picked up by URGENT transportation. Any other drop-off arrangements must be made by my contact with a staff member—either by phone or written consent. I can expect my child(ren) to be dropped off within an hour of each event’s ending time, unless delayed by vehicle, traffic, or weather issues. I understand that they will always have access to a phone, and are responsible to notify me of any schedule changes. Moreover, URGENT policy requires that youth may travel to and from agency sponsored events and trips via Private or Chartered transportation. However, there are some instances that travel by personal vehicle occurs. It is the responsibility of Administration or designee in charge to make sure that the release of liability form be filled out properly and on file at agency before any private vehicle transportation takes place. Children/Youth who ride with other participants/adults to and from agency sponsored events or trips do so at their own risk. URGENT endeavors to obtain confirmation of insurance for private vehicle transportation; however, URGENT does not certify that private vehicles have adequate insurance coverage. _____ [Initial] WATER ACTIVITIES

N/A We the undersigned parent and/or guardian understand that some activities include activities in or near water. I give permission for my child to participate in all water activities included in the program. For some water activities, participants must be able to swim. _____ [Initial] PHOTO/SOCIAL MEDIA CONSENT I hereby consent to and authorize the use and reproduction of any and all photographs, film and/or video that have been taken of my family and I for all advertising, publicity, social media and education purposes of Urgent, Inc. or anyone authorized by Urgent, Inc. I waive all claims for any compensation for such use or for damages. All negatives and positives, videotape and film, together with the prints and copies, shall constitute the property of Urgent, Inc., solely and completely.

mailto:[email protected]

http://www.urgentinc.org/

Youth : Last Name ___ , First ________ __

URGENT, INC. l 1000 NW 1ST AVE. STE 100 MIAMI, FL 33136 l 786-439-1544PH [email protected] l WWW.URGENTINC.ORG

_____ [Initial] RELEASE OF MINORS All participants are released at the end of the program day or activities to their parent/caregiver or one of the individuals listed on the application unless otherwise authorized below:

Release to parent/caregiver only Walk home Public/Private Transportation Other_________________________ *Reminder: Photo identification must be provided at time of pick-up. In addition to the names already listed on this application, my child may be released to the following individual (s): Name: Phone: Relationship: Name:

Phone: Relationship:

_____ [Initial] SCHOOL RECORDS RELEASE I authorize Miami-Dade Co. Public Schools to release school records information pertaining to grades, attendance and behavior referrals to an authorized person(s) acting on behalf of Urgent, Inc. _____ [Initial] RELEASE OF INFORMATION TO ACCESS ADDITIONAL SERVICES I authorize Urgent, Inc. to release identifying information about my family and I, upon my prior notification, in order to access additional services and support for myself or my children.

_____ [Initial] HIPAA NOTICE OF PRIVACY PRACTICES How We Collect Information About You: URGENT, Inc. and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails, and from the submission of applications that is either required by law, or necessary to process applications or other requests for assistance through our organization. What We Do Not Do With Your Information: Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence. We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about our clients who apply for or actually receive our services. This information is considered confidential. How We Do Use Your Information: Information is only used as is reasonably necessary to process your application or to provide you with our services and which may require to communication between other social service providers, or funding agencies including The Children’s Trust, City of Miami, Miami-Dade County, Alliance for Aging and other providers as necessary to access resources to provide you and your family services. If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law. _____ [Initial] SERVICE VERIFICATION I authorize the The Children’s Trust, City of Miami, SEOPW CRA, Miami Dade County, US HUD, and US Congress to contact me to verify that my family and I are receiving services, if applicable. _____ [Initial] ELIGIBILITY CRITERIA (AGE 55+) No financial criteria must be met in order to participate in activities or services. In order to receive services, I attest I am a resident of Miami-Dade County. _____________________________________________ ______________________________________________ PARENT NAME CHILD NAME _____________________________________________ ____________ SIGNATURE PARENTAND/OR GUARDIAN DATE

mailto:[email protected]

http://www.urgentinc.org/

cra summer youth training institute · 2013-09-10 · cra summer youth training institute . south...

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