One application will be accepted for each applicant. Completed applications will be entered into a lottery to determine those applicantswho will be offered a position in the Summer Youth Employment Program. SUBMISSION OF AN APPLICATION DOES NOTGUARANTEE ELIGIBILITY OR PLACEMENT INTO THE PROGRAM.1
. Social Security Number- -
. Last Name
. First Name
Month Day Year
U.S. CitizenPermanentResident AlienOther
. Street Address
(number and street)
Email AddressLast Name First Name
Name of Parent orLegal Guardian
(Area code) (Area code)
Emergency ContactPhone Number- -
White (Non – Hispanic)
Student in HS orbelowCollege student HS graduate GED recipientLeft HS beforegraduating
Current grade if in HighSchool or below
If not in HS, lastgrade completed
.If applicant is a male 18 and over, ishe registered with Selective Service?Yes No
. Check here if the applicant has a disability
Is applicant currently in the foster care system?
Is applicant or applicant’s family currently receivingpublic assistance?
If No, proceed to question 25.
.Type of Public Assistance
(Check all that apply)
Family Assistance (formerlyknown as AFDC)Food Stamps S.S.I. Safety Net/HomeRelief Other
.Total family income (gross) for the prior calendar year $
Number of family members currently living in applicant’s household
Is the applicant or any member of the household (0-64 years of age) covered by Medicaid, Child Health Plus, FamilyHealth Plus or private medical insurance?
I, the undersigned, certify that all information on this form is true and correct. I understand that my statements are subject to verification. I furtherunderstand that any false statements may subject me to criminal prosecution under both New York State Penal Laws, section 175.35 and Federal Law, 18U.S.C.A. 1001, and to civil action for return of all monies received. I agree and accept that I will abide by all applicable rules and regulations of thisprogram.Applicant Signature Date Parent/Guardian Signature Date
(Required if applicant is under 18 years of age)
Intake Officer Signature Date
The status of your application can be found atwww.nyc.gov/dycd
City of New YorkDepartment of Youth and Community Development
2008 Summer Youth Employment Program
Michael R. BloombergMayor
Jeanne B. MullgravCommissioner
If NO, do you want to be contacted with information about public health insurance programs?