CareerONE(Paynesville/ Sauk Centre Locations) 2018 Request Form
After completing the request form return to: Career Solutions
1542 Northway Drive, Door #2, St. Cloud, MN 56303 Email: Fax: 320-308-1717
Questions? Call Sara 320-308-5713 or Jeni 320-308-5728
Priority given to applications received by May 4, 2018. Requests accepted until July 30, 2018(Must be over 14 and not over 17 to submit a request.)
PLEASE PRINT and answer ALL QUESTIONS
BASIC INFORMATION:
First Name:______Middle Initial:_____ Last Name:______
Address: ______Apt#:______City:______State: MN Zip Code:______
County: Stearns Benton Other: ______Primary Email:______
Is this a: Youth email Parent email
Phone #:______2nd Phone #: ______Can we text? Yes No
Date of Birth ____/____/_____Age: ______School: ______School Counselor: ______
FAMILY/Demographic INFORMATION:
How many family members live with you? ______What is your family’stotal MONTHLY income? $______
(Income is based on Federal Register guidelines.)
(Optional) Gender: Female Male
(Optional) Race: Amer. Indian/Alaska Native Asian Black or African American Hawaiian/Pacific Islander
Hispanic Two or more races White
Eligibility Information:
Eligibility is based on the criteria below. Please check all statements that apply to you.
___ I receive free/reduced lunch at school___ I am an offender or in a diversion program
___ My parent is a Dislocated Worker___ I am pregnant or parenting
___ I live in a Foster Home or have experienced ___ I have drug and/or alcohol issues
out of home placement___ I am a child of a drug and/or alcohol abuser
___ I and my family receive Public Assistance (MFIP, Food ___ I am a high school dropout
Stamps)___ I have a diagnosed disability (includes ADD, ADHD,
___ I am behind one or more grade levels in a required depression, etc.)
___ I receive group home services___ I have limited English speaking ability
academic class required for graduation___ I am homeless or have run away
___ I attend an alternative school or may drop out
How did you hear about CareerONE? Sibling/Friend School Other: ______
Applicant/Parental/Guardian Consent:
I give permission to share my/the youth’s name with their school/county human services/corrections, for purposes of verifying the above information, and to obtain school records. These school records include, attendance, transcripts, discipline and MCA/STAR scores. In order to be considered for this program, I understand that I have to demonstrate reading/math skills at a 5th grade level on the TABE assessment. I also agree that I/they can read social cues, show that I/they can work safely in a team setting with minimal supervision, and I/they am in control of my emotions.
Youth Signature (Required): ______Date: ______
Parent/Guardian Sign*(Required): ______Date: ______
Parent/Guardian Printed First and Last Name Please*: ______