py 2016 - wioa - program participaton and income ... · web viewi understand i have the right to...

WorkSource DeKalbYouth Services Program

Eligibility Packet

WorkSource DeKalb (WSD) is an EEO/M/F/D/V employer/program. Auxiliary aids/services are available upon request to individuals with disabilities. Persons with hearing impairments may call 1-800-255-0135 or 711 (TTY) for assistance. WSD is fully funded by the U. S. Department of Labor and is a proud partner of the American Job Center Network.

Version 0412.2017

WIOA YOUTH ELIGIBILITY DOCUMENTATIONPROOF OF

IDENTIFICATION

PROOF OFCITIZENSHIP

PROOF OF RESIDENCY

PROOF OFBIRTH

PROOF OF HOUSEHOLD INCOME

PROOF OF SELECTIVESERVICEREGISTRATIO

N(MALES ONLY)

PROOF OF EDUCATION

ENROLLMENT STATUS

High School Transcript orWithdrawal Forms High School Diploma Post-Secondary

Transcript or DegreeAdditional documentation may be required based upon individual needs assessments.

For questions, please contact our office at (404) 687-3400 or visit our website at www.worksourcedekalb.org .


Version 0412.2017

Jane Carole Doe

http://www.worksourcedekalb.org/

WIOA YOUTH BARRIERS & DOCUMENTATIONPREGNANT

Definition:Participant that is clinically diagnosed as being with child, yet to be born.

Documentation:Doctor’s note, Visible Acknowledgment

PARENTINGDefinition:Participant that is a parent to a child.

Documentation:Birth Certificate of the Child

OFFENDER Definition:Any Participant who has been involved in the criminal justice process for whom services under this Act may be helpful or who needs assistance in overcoming artificial barriers to employment resulting from a record of arrest or conviction.

Documentation:Criminal record, a letter from a judicial court representative

HOMELESS Definition:Please reference the definition provided in subsection (a) and (c) of sections 103 of the Stewart B. McKinney Homeless Assistance Act (42 U.S.C. 11302).

RUNAWAY Definition:Participant who has consciously left his/her for various circumstanstial reasons.

Documentation:Letter/Record from a judicial court or public safety representative

FOSTER CAREDefinition:Participant that is in the custody of the state or local government.

Documentation:Letter from the State or State agency

BASIC SKILL DEFICIENT

Definition:English reading, writing or computing skills at or below the 8th grade level.

Documentation:Generally accepted standardized test

SCHOOL DROP OUT Definition:Participant who is not in school and who has not received a secondary school diploma or a General Equivalency Diploma (GED).

Documentation:Executive Withdrawal/Release Forms

IN SCHOOL YOUTH

Definition:Participant who is enrolled:

(a) In a secondary school(b) In a post-secondary educational institution

Documentation:Current transcript

OUT OF SCHOOL YOUTH

Definition:Participant that is not enrolled in any educational institution due to:

(a) Withdrawal status; or (b) Enrollment confirmation letter from Job Corps on letterhead(c) Completion of educational program (i.e. High School Graduate, GED Recipient)

Documentation:Executive Withdrawal/Release Forms, High School Diploma, or GED

Please always reference the Department of Labor’s website for current WIOA definitions.


Version 0412.2017

Documentation for an Independent Individual(Family of One)

I certify that, _____________________________________________________________________________________ (Appl icant Name) (Socia l Secur ity Number) (Date)

I am 18-24 years of age and receive less than 50% of my support (food, clothing, shelter) from my parent/legal guardian.

I am 14-18 years of age and not living with my parent/legal guardian and receive less than 50% of my support (food, clothing, shelter) from my parent/legal guardian.

I am 18-24 years of age, living with my parent/legal guardian, and contribute to my own support through my earned income. A work history is evident through a Wage Inquiry (GWS) or Employer Statement or pay stubs from my employer during the past six months.

I am a foster child on behalf of whom the state or local government payments are made

I am incarcerated or institutionalized or I am a Ward of the State.

Your signature below acknowledges that the information you provided is true and that you have read and understand the criteria by which you qualify to receive Workforce Innovation and Opportunity Act services.

______________________________________________________________________________________________ (Person ver ify ing the appl icant ’s s ta tus) (Relat ionship to the Appl icant) (Da te )

______________________________________________________________________________________________ (Person ver ify ing the appl icant ’s s ta tus address ) (Person ver ify ing the appl icant ’s s ta tus contact number)


Version 0412.2017

The following questions assist the WSD staff within the Youth Services Program assess whether or not youth participant candidates are “ELIGIBILE ” and “SUITABLE ” for the Workforce Innovation & Opportunity Act – Youth Program for WorkSource DeKalb. Candidate Questions – Section A:

What is your name?What school do you attend?

Do you have a high school diploma or GED? YES NOWhat was the name of the high school or GED Program?

Do your currently attend -OR- have you attended college in the past?

YES NO

What is/was the name of the College or University?

What is your current grade?How old are you?

Needs Additional Assistance Related Questions:

Do you need assistance completing your education or finding employment?

YES NO

Do you live in a single parent household? YES NODo you live in a household where one or more parents are unemployed?

YES NO

Have -OR- are one or more of your parents incarcerated? YES NOAre one or more of your parents deceased? YES NODo you currently live with someone OTHER THAN one or both of your parents?

YES NO

Candidate Questions – Section B:

1. In order to provide better service to you, are you willing and able to complete quarterly assessments which include, but are not limited to, testing, interviews, and community service activities?

2. Why do you want to be in the WorkSource DeKalb – Youth Services Program? 3. How would your parents, teachers, or mentors describe you?4. How would your friends describe you?5. Name one of your strengths and one of your areas of improvement?6. Where do you see yourself in the next 2-5 years?7. Who is your role model and why?8. If you were enrolled in the program, what are the characteristics that you would want your

Case Manager to have?

Participant (Print Name) Participant (Signature) Date of Birth Last 4 of SSN Date


Version 0412.2017 PAGE 5/2

Parent/Guardian (Print Name) * Parent/Guardian (Signature)*

Date

*Parent/Guardian signature required for program participants who are less than eighteen years of age.



PROGRAM PARTICIPATON PROFILE & HH COMPOSITION FORM774 JORDAN LANE, BUILDING 4, DECATUR, GA 30033, (404) 687-3400 OFFICE, (678) 834-8884 eFAX

Thank you for your interest in the Workforce Innovation & Opportunity Act (WIOA), 2014 Program via WorkSource DeKalb. This income eligibility form will be used to verify your household income and to determine eligibility to participate in programs funded by the Workforce Innovation & Opportunity Act (WIOA), 2014. Falsification of Data on this form is a crime against Federal and State laws.

CONTACT INFORMATIONLast Name First Name M.I. Gender

Male FemaleSSN

Street Address County City State Zip Code

Date of Birth(Month/Date/Year)

Age Race American Indian/ Alaskan Native Asian Black or African American White Hispanic or Latino Other

Home Phone Cell Phone Email

Facebook Twitter Other Social Media

EDUCATIONAL BACKGROUND INFORMATIONSchool Enrollment Status HS Student HS Graduate

HS Drop Out 2-year College Job Corp 4-year College

If applicable, check the credential you have received: High School Dipl. GED Occupational Cert. Associate Degree Bachelor Degree

If you have not received a high school diploma, GED, or occupational certificate, please check the highest grade that you have completed: Below 8th grade 8th grade

9th grade 10th grade

11th grade 12th grade, w/o diploma

INCOME ELIGIBILITY INFORMATIONLIST EVERYONE LIVING IN THE HOUSEHOLD, INCLUDING STUDENTS

Number in Family (including self)

Annual Family Income $

LIST EVERYONE LIVING IN THE HOUSEHOLD, INCLUDING STUDENTSNames of Household Members, including applicant

Relationshipto applicant

Age Household Member’s SS Number

Income (From 6 months prior to date of this application)

- SELF -

Please list the name, relationship to the participant, and the full social security number of all the



household members on this form. Completing this information does not guarantee enrollment in to WIOA funded programs.



DECLARATION, RIGHTS AND RESPONSIBILITIESI understand my signature on this form is a declaration that information I have provided is true and correct. I understand I have the responsibility to report any changes in my household that may affect eligibility. Falsification of data on this form is a crime against Federal and State laws. I further understand that falsification or concealment of information is punishable by a fine or imprisonment or both and will require repayment of any monies paid to, or on behalf of, the applicant while in a training program.

Participant Initial Parent/Guardian InitialI understand my application will be processed within 30 days and I will receive a written notice outlining the level of service for which I have been approved.

Participant Initial Parent/Guardian Initial

I understand that I will be notified in writing using the address listed when I registered for consideration to be enrolled in the youth services program, should my enrollment be denied.


I understand I have the right to complain if I feel I have been discriminated against, mistreated, or disagree with the decisions made that affect me. I understand that those complaints are handled through the WIOA NON-DISCRIMINATORY GRIEVANCE AND COMPLAINT PROCEDURES. Should my complaint be of discrimination, I understand I may alternatively contact the Directorate of Civil Rights at the U.S. Department of Labor, or the Civil Rights Manager at the regional office of the U.S. Department of Health and Human Services, as appropriate. I may follow either procedure (local or Federal), but cannot follow both simultaneously. I know that the EEO Officer is located at the WorkSource DeKalb Office at 774 Jordan Lane, Building 4, Decatur, GA 30033, and I will be provided all necessary information to assist me in exercising my rights under the Civil Rights Act, civil rights provision under program-specific laws, and in proceeding with complaints regarding non-civil rights issues.


I understand that it is my right and responsibility to notify my WIOA Case Manager if I require assistance in completing any forms because of physical or mental disability, inability to speak English, or other difficulties. Participant Initial Parent/Guardian InitialIf I am an adult male (over age 18) at the time of my program enrollment, and I am not currently registered with the Selective Service, I authorize the WIOA Case Manager to register me for the Selective Service using my personal information.

Participant Initial Parent/Guardian InitialIf I am currently receiving food stamps or TANF benefits from the Department of Human Services, or have received benefits within the last 6 months, I authorize Department of Human Services (DHS) to release this information to WIOA for the purposes of determining eligibility.

Participant Initial Parent/Guardian InitialI attest that I am the parent or legal guardian for the below signed participant.

Participant Initial N/A Parent/Guardian Initial

My signature on this form indicates I have read the statements presented or had them explained to me. I have been given the opportunity to ask questions and gain clarification on any issues I did not understand. Participant Initial Parent/Guardian Initial

RELEASE INFORMATIONI authorize the release of information to the WorkSource DeKalb Staff as necessary to determine my eligibility for the Workforce Innovation & Opportunity Act (WIOA), 2014 Youth Services Program and related services and to determine progress, completion, and credentials attained; further, the release of information by staff necessary to secure related services, assistance on my behalf, and share information with other programs from which I receive or have received services such as DeKalb WIOA Partners, DeKalb County Board of Education, Vocational Rehabilitation, Decatur/DeKalb Housing Authority, DeKalb Division of Family & Children Services (DFACS), Department of Labor, Georgia Piedmont Technical College and Georgia Perimeter College. The authorization to share necessary and pertinent personal information about me is given with the understanding that the information will be used in a confidential and responsible manner.

Applicant’s Signature (If candidate is under age 18, a parent or legal guardian must sign below) Date

Parent/Guardian’s Signature Date

WorkSource DeKalb (WSD) is an EEO/M/F/D/V employer/program. Auxiliary aids/services are available upon request to individuals with disabilities. Persons with hearing impairments may call 1-800-255-0135 or 711 (TTY) for assistance. WSD is fully funded by the U. S. Department of Labor and is a proud partner of the American Job Center Network. Version 0412.2017

WorkSource DeKalb (WSD) is an EEO/M/F/D/V employer/program. Auxiliary aids/services are available upon request to individuals with disabilities. Persons with hearing impairments may call 1-800-255-0135 or 711 (TTY) for assistance. WSD is fully funded by the U. S. Department of Labor and is a proud partner of the American Job Center Network. Version 0412.2017

Affidavit

This page must be signed in the presence of a notary. If you are unable to have notarized personally, a Notary Public is available at WorkSource DeKalb. All Workforce Innovation and Opportunity Act (WIOA) Applicants must submit a signed, notarized O.C.G.A. Affidavit.

O.C.G. A. § 50-36-1(e)(2) AFFIDAVIT

By executing this affidavit under oath, as an applicant for Workforce Innovation and Opportunity Act Services as referenced in O.C.G.A. § 50-36-1, from WorkSource DeKalb, the undersigned applicant verifies one of the following with respect to my application for a public benefit:

1) _______ I am a United States Citizen.

2) _______ I am a legal permanent resident of the United States.

3) _______ I am a qualified alien or non-immigrant under the Federal Immigration and

Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency.

My alien number issued by the Department of Homeland Security or other federal immigration agencyis:

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, such as a Georgia Driver’s License, US Birth Certificate, US Permanent Resident Card, or Alien Registration Receipt Card , as required by O.C.G. A. § 50-36-1(e)(1), with this affidavit. A complete list of acceptable documents is attached.

The secure and verifiable document provided with this affidavit can best be classified as:.

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute.

Executed in (city), (state).

____________________________________*Signature of Applicant

____________________________________Printed Name of ApplicantSUBSCRIBED AND SWORNBEFORE ME ON THIS THE

DAY OF , 20

___________________________________NOTARY PUBLIC

My Commission Expires:

Affidavit_____________________________

Customer Assent and Parent/Guardian Consent Form

A Customer Assent and Parent / Guardian Consent form must be completed for each Workforce Innovation and Opportunity Act, 2014 customer who is under 18 years of age at registration and served with youth funds. The Assent / Consent form must be retained for a minimum of one year after the customer’s exit.

Customer Assent

I, , understand that I may be asked to take part ina customer satisfaction survey after I receive services. I agree to answer the survey questions if asked to do so.

Signature of customerDate

Emancipated Youth Yes No

Parent / Guardian Consent

I, , give my consent for my child / ward to answer questions in a customer satisfaction survey.

Signature of customerDateRelationship to customer


Version 0412.2017

WorkSource DeKalb (WSD)Workforce Innovation and Opportunity Act (WIOA)

Grievance/Complaint Procedures and Equal Opportunity PolicyGeneral PolicyWhenever any person, organization or agency believes that the Governor, or the Governor’s designee, Workforce Innovation and Opportunity Act (WIOA) grant recipient, or other subrecipients (e.g. service providers, contractors) has engaged in conduct that violates the Workforce Innovation and Opportunity Act and has a concern regarding this violation, the problem should first be discussed informally between those involved before a grievance or complaint is filed.

The grievance or complaint process is intended to allow for a resolution of the violation at the most local level. Applicants and participants for WIOA related services through the Workforce Innovation and Opportunity Act (WIOA) Title I will be treated fairly by WorkSource DeKalb (WSD) and Georgia Department of Economic Development, Workforce Division or any of its subrecipients for funds entrusted to the agency and no applicant, participant, employee, service provider or training provider will be intimidated, threatened, coerced or discriminated against because they have made a compliant, testified, assisted or participated in any manner of an investigation, proceeding or hearing.

Equal Opportunity PolicyWorkSource DeKalb adheres to the following United States Law: "No individual shall be excluded from participation, denied the benefits of, subjected to discrimination under, or denied employment in the administration of or in connection with any such program because of race, color, religion, sex (including pregnancy, childbirth, and related medical conditions, transgender status, gender identity), national origin, age, disability, or political affiliation or belief and against beneficiaries on the basis of either citizenship status or participation in any WIOA Title I-financially assisted program or activity. References include WIOA Title 1, Title VI of the Civil Rights Act of 1964, Section 504 of Rehabilitation Act of 1973, The Age Discrimination Act of 1975, Title IX of the Education Amendments of 1972, and 29 CFR §38.25. Complaints of DiscriminationWorkSource DeKalb is prohibited from discriminating, under Section 188 WIOA Nondiscrimination and Equal Opportunity Regulations (29 CFR Part 38) Final Rule in the Federal Register, against all individuals in the United States on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief, and against beneficiaries on the basis of either citizenship/status as a lawfully admitted immigrant authorized to work in the United States or participation in any WIOA Title I financially assisted program and activities. The complainant has the right to be represented in the complaint process by an attorney or other representative.

Grievances and complaints should be filed as the participant’s right in accordance with the written procedures established by WSD in this subsection for WIOA funded program or activity whether informally or formally signed and in written form. If you think that you have been subjected to discrimination under a WIOA-funded program or activity, you may file a complaint within 120 days from the date of the alleged violation to the WIOA Equal Opportunity Officer at WorkSource DeKalb. If you elect to file your compliant with the Georgia Department of Economic Development, Workforce Division, you must wait until WorkSource DeKalb has issued a decision or until 90 calendar days have passed, whichever is sooner, before filing with the Georgia Department of Economic Development, Workforce Division.

After 60 calendar days of filing your grievance, the Georgia Department of Economic Development, Workforce Division requires WorkSource DeKalb (local WIOA area) to provide a formal decision, if the issue is not resolved informally. If you find the local hearing decision unsatisfactory, or if the local area does not respond to you in the allotted 60 days, you will have the opportunity to file a request for review by the Georgia Department of Economic Development’s Workforce Division by using the WIOA Complaint Information Form via http://www.georgia.org/wp-content/uploads/2014/06/WFD-Grievance-Form- 110915.pdf . Furthermore, the complainant or griever reserves the right to directly file their discrimination-based Complaint with the United States Department of Labor’s Civil Rights Center at: http://www.dol.gov/oasam/programs/crc/external-enforc-complaints.htm.


Version 0412.2017

If the complainant is dissatisfied with the resolution of his/her complaint by WorkSource DeKalb or WFD, the complainant may file a new complaint with CRC within thirty (30) days of the date on which the complainant receives the Notice of Final Action. If the State or WorkSource DeKalb fails to issue the Notice within ninety (90) days of the date on which the complaint was filed, the complainant may file a new complaint with CRC within thirty (30) days of the expiration of the ninety (90) day period (in other words, within one hundred and twenty (120) days of the date on which the original complaint was filed). Additional information regarding grievance and complaint filling, hearing process and timeline are outlined in WorkSource DeKalb’s Policy Manual that can be requested from WorkSource DeKalb’s EEO Officer listed below.

I. Contact Local Area – WorkSource DeKalb for inquiry to resolution of alleged grievance or complaint Sandeep GillDeputy Director/Equal Opportunity OfficerWorkSource DeKalb774 Jordan Lane, Building 4Decatur, Georgia 30033Email: [email protected]: (404) 687-3437 Fax: (404)687-4099

II. Contact State WIOA EO OfficerWIOA Title I Equal Opportunity Officer Mr. David DietrichsDeputy Counsel Georgia Department of Economic Development, Workforce Division 75 Fifth Street, NW, Suite 845 Atlanta, GA 30308 404-962-4136 (voice)

ORBen Hames, Deputy Commissioner Georgia Department of Economic Development, Workforce Division75 Fifth Street, NW, Suite 845Atlanta, Georgia 30308 Phone: (404) 962-4005Fax: (404) 876-1181

III. If resolution is not sufficient, contactDirector, Civil Rights Center (CRC), U.S. Department of Labor 200 Constitution Ave. NW Room – N4123 Washington, DC 20210

And Regional AdministratorUSDOL/Employment and Training AdministrationAtlanta Federal Center, Room 6M11261 Forsyth Street, SWAtlanta, GA 30303

A complainant may file directly with the Director, Civil Rights Center at the address listed above. Or at the website: http://www.dol.gov/oasam/programs/crc/external-enforc-complaints.htm.

In case of suspected fraud, abuse or other alleged criminal activity, you should direct your concerns to the Georgia Office of Inspector General, 1-866-435-7644 or email at [email protected] . There is no charge for this call. Complaint Form: http://oig.georgia.gov/file-Complaint . This document can be translated using www.microsofttranslator.com

Additionally, as part of DeKalb County Government’s commitment to a “Zero Tolerance” of unethical conduct in the workplace, DeKalb has implemented an EthicsPoint Hotline that is hosted/managed by a third-party provider. This service provides anonymous and confidential reporting of unethical conduct in DeKalb County. Access to the system is available 24/7 via telephone at 855-224-8216 or online at www.co.dekalb.ethicspoint.com. Each report will automatically generate a unique 10-digit Report Key to allow the tracking status of reports submitted. All reports are sent electronically to the County’s Internal Auditor for review and investigation. For more information, see DeKalb County Ethics Policy.

I certify that I have received a copy of this policy and procedures.

Applicant Name (signature): Date:


Version 0412.2017

http://www.microsofttranslator.com/

http://oig.georgia.gov/file-Complaint

mailto:[email protected]

http://www.dol.gov/oasam/programs/crc/external-enforc-complaints.htm

Authorization to Share and Release InformationI authorize representatives of WorkSource DeKalb to share/release the information listed below with employers and with public or private agencies from which I receive assistance or with agencies from which I may request assistance or which I may be referred by the WorkSource DeKalb for assistance. Information regarding my educational matriculation may be released to WorkSource DeKalb. Individual student information will not be published externally or used for any purposes other than internal data analysis.

Confidential/Personal Information on file (i.e. Proof of Citizenship, Proof of Birth, Proof of ID, etc…) School Records (Attendance, test scores/results and dates of graduation) Academic Progress Reports (i.e. report cards, transcripts, class schedules) Enrollments, no shows and withdrawals Behavioral Conduct Reports (Individual Service Strategies or IEP’s) Income Verification (i.e. Free/Reduce Lunch confirmation) Decisions or Results from Universities or Technical College System of Georgia (TCSG) regarding

special accommodations, etc.

I authorize my employer to release the following information regarding my employment to WorkSource DeKalb. Individual employee information will not be published externally or used for any purposes other than internal data analysis.

Confidential/Personal Information on file (i.e. Proof of Citizenship, Proof of Birth, etc…) Work History (Employment Record including start dates or end dates of employment) Date of Employment Job Title (Positions held) Description of Responsibilities Salary (Wages paid per hour) Performance Reviews, Evaluations and References

If applicable, I authorize verification of my continued education at a University or College to WorkSource DeKalb. Individual student information will not be published externally or used for any purposes other than internal data analysis.

Confidential/Personal Information on file (i.e. Proof of Citizenship, Proof of Birth, Proof of ID, etc…) Enrollment, Attendance, Student Account, and Financial Assistance (FAFSA, Pell, Private Loan) Degree Program Academic Progress Reports (i.e. transcripts, class schedules) Behavioral Conduct Reports

I authorized the release of confidential medical related information, which include but is not limited to drug and alcohol screenings. Additionally, I authorize WorkSource DeKalb to conduct a background check, which includes, but is not limited to, credit or criminal records. I understand that this information will be used in providing Workforce Innovation and Opportunity Act, 2014 services. The services include academic enrichment, career development planning, and supplemental education. It is understood that the party to whom this information is released will not be released to a third party without authorized consent.

I understand that the Workforce Innovation and Opportunity Act, 2014 – Program via WorkSource DeKalb is a WIOA training program geared toward the acclimation and preparation for program participants to transition into self-sustaining employment, advanced education, or the United States Armed Forces after obtaining a nationally recognized credential.


Parent/Guardian (Print Name) * Parent/Guardian (Signature)* Date



Version 0412.2017

Media Release Form

I , hereby allow WorkSource DeKalb (WSD) the irrevocable right to utilize my actual or likeness of my image or voice for WSD approved photographs, videos, publications, internet, news and social media and web pages for special projects or publicity.

I am aware that I may be asked a variety of questions concerning WSD and WSD related activities and programs, and that the contents of the interview may be published or aired publicly. I understand that I will be under the supervision of a WSD staff member during the interview or photo session. There may or may not be WSD staff supervision for photographs or video/voice recordings that are part of a general background scene in which I am not specifically identified.

I reserve the right to refuse to answer any questions or participate in any discussions that make me feel uncomfortable or embarrassed. Additionally, I and/or the supervising WSD Staff member reserves the right to terminate the interview, photo or video session at any time for any reason.

I understand that neither WSD, nor the news media, has any obligation to air or publish my image, photos, videotape and/or voice. I also understand that I will not receive any monetary compensation for the rights granted herein. Furthermore, I understand that my appearance or the use of my voice in any publication, photo, internet or televised form does not confer any ownership rights to me. If by reason of my statements and actions in the interview, photos, images, videotape and/or voice recording, or the materials furnished to myself by anyone other than the WSD for the same, there is any claim or litigation involving any charge by third parties of violation or infringement of their right, I agree to indemnify and hold harmless WorkSource DeKalb, its staff, DeKalb County and its licensees, and assignees from liability, loss or expenses arising from such claim or litigation.





Version 0412.2017

Drug Screen Notification & Authorization

I , authorize and hereby and understand that I may be required to take a drug screen(s), which include but is not limited to a DNA or urine sample test, as requested by a representative of WorkSource DeKalb or a third party vendor working with WorkSource DeKalb .

I do understand that a positive result on this test may be an indication of substance use. Should this test indicate positive result(s):

my acceptance into the program or services may be interrupted Referrals to work-related opportunities may be discontinued until further notice I may be asked / required to seek further substance use / abuse assessment for services

to be continued

In addition to the above, I give permission for WorkSource DeKalb staff or a third party vendor working with WorkSource DeKalb to consult with teachers, counselors, and other administrative personnel as deemed necessary. I understand that these records and consultations are confidential and that they will be used only to help the WorkSource DeKalb staff or a third party vendor working with WorkSource DeKalb to determine what actions would be most beneficial for the program participants.

I understand that the Workforce Innovation and Opportunity Act, 2014 – Program via WorkSource DeKalb is a WIOA training program geared toward the acclimation and preparation for program participants to transition into self-sustaining employment, advanced education, or the United States Armed Forces after obtaining a nationally recognized credential.





Version 0412.2017

Emergency Contact & Medical Information FormPlease complete the following medical information for our records. This information will only be used in the event that you have a medical emergency that requires immediate attention while under the supervision of WorkSource DeKalb personnel or third party vendors working with WorkSource DeKalb.

Participant Name:Participant Address:Participant Address:Participant Contact#:Participant Email Address:

Emergency Contact Name:Emergency Contact Address:Emergency Contact Address:Emergency Contact#:Emergency Email Address:

Emergency Contact Name:Emergency Contact Address:Emergency Contact Address:Emergency Contact#:Emergency Email Address:

Do you have any medical conditions?If yes, please explain below:

YES

NO

Do you have any allergies to food or medications?If yes, please explain below:

YES

NO

In case of an emergency, do you grant WorkSource DeKalb permission to perform basic first aid and/or CPR?

YES

NO

In case of an emergency, do you grant WorkSource DeKalb permission to contact 911 on your behalf?

YES

NO

Participant (Print Name) Participant (Signature) DOB Last 4 – SSN Date

Parent/Guardian (Print Name) * Parent/Guardian (Signature) * Date



Version 0412.2017

py 2016 - wioa - program participaton and income ... · web viewi understand i have the right to...

Documents