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Crispus Attucks Center for Employment and TrainingSummer ApplicationDocuments needed HS Diploma Social Security Card Birth Certificate PA State ID and/or School record 6 months of Participant’s income information: 30 days ofpay stubs, Food Stamps, SSI and/or IEPOnly fill out the highlighted areas onlyDO NOT DATE APPLICATIONCompleted application can be returned at: 620 SouthGeorge Street, York 17401 on the following days only:Tuesday 1- 5pmWednesday 1- 5pmThursday 1- 5pmApplication DeadlineJuly 9thParticipant Name: Age: T-Shirt Size:Summer Program of Interest: circle one belowSummer Workforce Online ProgramContact Tracing – HACCWorkPath ManufacturingCNA Readiness

Crispus Attucks Center for Employment and TrainingSummer ApplicationParticipant Name: Age: T-Shirt Size:Summer Program of Interest: circle one belowSummer Workforce Online ProgramContact Tracing – HACCWorkPath ManufacturingCNA Readiness

TANF APPLICATION/WIOA PRE-APPLICATIONApp. Date:WIOA TANF In-School Out of School Participant Basic InfoLast Name: First Name: PID#:Street: City: Zip:County: York Documentation: Driver’s Lic. State ID Benefit Letter ISY: School Record Report CardParticipant Phone #:Gender: Male Female Age: Documentation: Birth Certificate Alien Reg. Card I-94 I-551Race: White Black/African Am. Hispanic/Latino Am. Indian or Alaskan Native Asian Hawaiian Native or other Pacific Islander Do not wish to disclose Citizen: Yes No Documentation: Birth Certificate Alien Reg. Card I-94 I-551SS#: Documentation: Social Security CardVeteran:Yes No Documentation: Separation Date:Selective Service (Males 18 & Older): Yes No N/A Documentation: Internet verification/registrationEducation Status:Not Attending-HS Graduate In-School, Alternative School Not Attending-HS Dropout In-School, HS In-School, Post HS Documentation: Report Card Transcripts DiplomaHighest Grade Completed:School Attending/Attended:Employment Status: Employed F/T P/T Unemployed Last Day Worked:Employer Name (if applicable):Barriers: If “Yes “is marked for any Barrier, please provide verifying documentation)Pregnant or Parenting:Yes No Documentation:Foster Child/Aging Out:Yes No Documentation:Homeless/Runaway:Yes No Documentation:School Dropout:Yes No Documentation:Offender:Yes No Documentation:Youth in Juvenile Justice System:Yes No Documentation:Basic Skills Deficient:Yes No Documentation:Individual with Disability:Yes No Documentation:Below Average Grade Level:Yes No Documentation:Requires Additional Assistance to complete an educational program or tosecure and hold employment:Yes No Documentation:Revised 05/2017Page 1SCWIB

Other Characteristics:PID#Adjudicated or at-risk of being court-involved: Yes Incarcerated Parent(s):Yes Child of Migrant Worker:Yes No No No PARTICIPANT’S Household Income & Family Size:Only the participant’s information should be recorded below. (Unless participant has a spouse or children onlythe participant information goes dentType/Source of6 MonthName /FamilyIncomeAmountMemberSELFFamily Size TotalTotal 6 Month IncomeProof of 6 month income (Participant): Documentation: Statement of Family Size/Family Income Pay StubProof of Family Size: Documentation: Statement of Family Size/Family Income Award Letter IEPReceiving TANF/Cash Assistance: Yes No Documentation:Receiving (or have in last 6 months) Food Stamps: Yes No Documentation:Receiving SSI: Yes No Documentation:Certification:I certify that the information provided is true to the best of my knowledge. I am also aware that the information I have provided issubject to review and verification and that I may have to provide documents to support this application. I am also aware that I amsubject to immediate termination if I am found ineligible after enrollment and may be prosecuted for fraud and/or perjury.I allow release of this information for verification purposes and understand that it will be used to determine eligibility.Signature of Applicant: / /SignaturePrintDateSignature of Parent/Guardian: / /(If applicant is under18 years old)SignaturePrintDateVerifying Staff Person: / /SignaturePrintDateSupervisory/Secondary Reviewer: / /SignatureTitleDateRevised 05/2017Page 2SCWIB

Participant Name:Participant Email Address:Parent/Guardian Basic InformationLast Name: First Name:Street: City: Zip:Work/ Daytime Phone: Cell:Email Address:Employer Name (if applicable):In case of an emergency, whom may CACET contact:Last Name: First Name:Street: City: Zip:Work/ Daytime Phone: Cell:Participant Allergies/Disabilities/Concerns CACET needs knowledge of:

ATTACHMENT HWORKFORCE INVESTMENT ACTSTATEMENT OF FAMILY SIZE/FAMILY INCOMEIDENTIFING INFORMATIONApplicant’s Name:LastFirstMIAddress:StreetCityZipParticipant ID#: Application Date:To be completed by TANF applicant with staff assistance.Only the participant’s information should be recorded below. (Unless participant has a spouseor children only the participant information goes below:PARTICIPANT NAMETotal number in Family:RELATIONSHIP TO APPLICANTFAMILY MEMBERS INCOME(Last Six Months)Total Income :I attest to the best of my knowledge that the information above is true and correct.Signature of ApplicantCORROBARTING WITNESS (Must be completed by a household member) I attest to the best of my knowledge thatthe information is true and correct.Name: Signature: Date:Address: Street: City: State: Zip:Telephone Number: Relationship to WIOA/TANF Applicant:

TANF YOUTH DEVELOPMENT PROGRAM (TANF YDP)Authorization for Release of InformationI hereby authorize and request the disclosure to the TANF YDP service provider any informationconcerning education and training activities and any additional information involving eligibilityfor myself. As a client in TANF YDP, I give permission to the TANF YDP service provider todiscuss my case with other agencies as needed to further my participation in TANF YDP. It isunderstood that the information obtained will be used only for purposes directly related to theparticipation and eligibility with the TANF YDP service provider.Organization Name and Address:Crispus Attucks Center for Employment and Training605 South Duke Street.York, Pa 17401Staff Name (please print)Staff Signature:Date:Client Name (please print) and Address:Date of Birth:Client Signature:Date:Signature of Parent or Legal Guardian (if client is under 18):Date:

PERMISSION TO TRANSPORTI , as the parent / legal guardian, of(PRINT PARENT OR GUARDIAN NAME)do herby give permission to Crispus(PARTICIPANT’S NAME)Attucks Association to transport for the purpose of Youth Employment Servicesactivities during the duration of my time in any Y.E.S Program. Only check box if you refuse to be transported by Crispus AttucksPHOTO RELEASEI permit the Crispus Attucks Center for Employment and(PRINT PARENT OR GUARDIAN NAME)Training (CACET), to use photographs in which(PARTICIPANT’S NAME)pictured and/or my name to promote its programs and services. I understand that mysignature on this form gives CACET permission to include my name and/or photosfeaturing my face or likeness of my person in public relations, marketing or othermaterials circulated among the public and business community-including brochures,newsletters, advertisements, posters and other materials- and as part of electronicmedia that may include websites, multimedia presentations and other vehicles ofcommunication. I understand that I will not be compensated in any manner for the useof my name or photo in which I appear.Participant signatureParent or Guardian Signature(If participant under age of 18)Staff SignatureDATE

Crispus Attucks Center for Employment and TrainingPolicy GuidelinesGrievance and Complaint Procedures1.0Policy Statement & General PrinciplesThe Crispus Attucks Center for Employment and Training (CACET) recognizes thatgrievances may arise in the normal course of client interaction, management andenrolment within programming; not limited to employment workshop training, casemanagement services, tutoring and guidance and in any services provided by thisvendor of the Workforce Investment Act and Temporary Assistance for Needy Families,more specifically of the South Central Workforce Investment Board. As such, throughoutthese funded activities, our staff is fully committed to ensuring that any such issues thatarise can be discussed openly and dealt with satisfactorily and promptly. This policyprovides a mechanism for the client to raise a grievance relating to any portion ofservice while enrolled within programming and up to twelve (12) months thereafter. Allgrievances will be dealt with in a confidential manner and no client/participant will bepenalised for raising a grievance in good faith.The Crispus Attucks Center for Employment and Training (CACET) will endeavour toensure that grievances are documented and resolved (if able to be accommodated atvendor/local level) within 7 working days of being received and that decisions arecommunicated within 7 working days of being heard.A parent, guardian or representative of client if applicable may accompany theclient/participant upon initiation of the complaint or any formal grievance meetings thatare held. It will be necessary to confirm details and document the accompanying party.In addition, a grievance or complaint can be made by a parent, guardian orrepresentative of the client if applicable.All meetings and outcomes will be documented and a copy given to the client. Inaddition, a copy will be placed in the client’s case file and also maintained with theadministrative offices of the Crispus Attucks Center for Employment and Training(CACET).2.0Grievance ProcedureAs stated above, the client is always encouraged to bring matters to the attention of ourstaff at the earliest possible stage informally. This should be done as issues arise and isnormally the most effective way to resolve matters speedily.If the client is not happy with the response received through the informal stage orwishes to raise a grievance formally in the first instance, the client should raise the issuein writing with their Case Manager or immediate staff. This should clearly set out the

nature of the grievance and make it clear that the formal grievance procedure is beinginvoked. If the grievance concerns the client’s Case Manager or immediate staff and isopposed to discussing the matter with them directly, the client may meet immediatelywith the next level of management (CACET Programs Manager).A meeting will be arranged with the client to discuss the grievance. If necessary, morethan one meeting will be held. A decision on the grievance will be confirmed in writingwithin 7 working days of the grievance meeting being held.If the client is not satisfied with the outcome after this stage of the process, the clientmay appeal the decision in writing to the CACET Director. If the client raised the matterinitially with the CACET Director, the matter may be referred to the South CentralWorkforce Investment Board for review and further action or guidance. The decision atthis stage will be considered final (at vendor level).When a problem or issue arises that cannot be addressed in this manner, or not ofsatisfactory resolution, or if further guidance is needed throughout the course of agrievance; the formal grievance procedure may be invoked in accordance to:e-CFR codes (Electronic Code of Federal 67.645§667.650AndWorkforce Investment Act 181(c)3.0 Statement of Affirmation and ReceiptThe signatures below affirm that the grievance policy and guideline has beenreviewed and a copy has been issued to the client upon enrolment of servicesprovided by the Crispus Attucks Center for Employment and Training.Client/Participant SignatureDateCase ManagerDate