The Work Force Youth Program

Creating Pathways to Success Through Connected Learning

General Application

Participant Information

Legal Name: ______Citizenship: ______Resident Alien Card? Yes___ No___

Phone Number: ______Participant’s Cell Phone: ______

Participant’s Email: ______Race/Ethnicity: ______

Social Security Number: ______Date of Birth: ______

Address: ______Zip Code: ______

School Information

School: ______(If at CRLS) Small School Community (circle one): C R L S

Dean: ______Guidance Counselor: ______

Learning Plan/Special Ed: Yes__ No___ Grade: ______Sports: Fall______Winter______Spring______

Tutoring Plus of Cambridge (Partnering with The Workforce):

Would you like your youth to have a tutor? Yes___ No___ Subject: ______

One-on-One tutoring will take place in the evenings from 6:00-7:30 p.m. every Monday at Jefferson Park, Tuesdays at Windsor St, and Wednesdays at Roosevelt Towers. Students must commit to a minimum of four months (one academic semester) of tutorial services. For more information on Tutoring Plus' program, please call 617-349-6588 x407, or www.tutoringplus.org

Emergency Contact

Name: ______Relationship: ______

Address: ______

Home Phone: ______Other Phone: ______

Parent/Legal Guardian Information

Parent/Guardian: ______Home Phone: ______

Work Phone: ______Cell Phone: ______Email: ______

Address: ______

Check any of the following sources of income for your family. Work _____ Pension _____

AFDC (Welfare) _____ unemployment check _____ social security: (type) ______

I hereby give my permission for my child to participate in The Work Force Youth Program. I have read the program contract and give my child consent to participate in all program activities and events. I also give permission to Cambridge Housing Authority to use images of my child for informational and promotional material. I am aware that I can contact my child’s Teacher/Counselor or the Program Director if I have any questions regarding my child’s participation in The Work Force Youth Program.

Jefferson Park (617) 499-7110 Roosevelt Towers (617) 499-7169 Windsor Street (617) 499-7107

______

Signature of Parent/Guardian Date

The Work Force Youth Program Cambridge Housing Authority 675 Massachusetts Ave. Cambridge, MA 02139

Phone: 617-520-6350 Fax: 617-520-6306 TDD: 1-800-545-1833, x112