Raspberry Pi Program Description:

In the Raspberry Pi Camp, students will engage in computer science topics utilizing the power of programming. The Raspberry Pi Computer platform will enable the students to learn how to manipulate aspects of a favorite video game called Minecraft through the use introductory programming techniques. The best aspect of the camp is students will completely construct their own Raspberry Pi computer to bring home. Through these activities, students will learn an introduction to computer science and Python programming language to use with their new RPi Computer. At the end of the session each student will take their computer home with them.

If you have any questions, please reach out to Shani Schalles or Danielle Schaufert.

Shani Schalles Danielle Schaufert STEM Programs Coordinator Admissions Coordinator SSchalles@HarrisburgU.edu DSchaufert@HarrisburgU.edu717-901-5100 x1740 717-901-5100 x0122

Harrisburg University of Science and Technology

2020 After School & Summer Camp Emergency Contact Form

Student Name: ________________________ Date: _______________

Participant ID: ________________

Primary Contact

Primary Contact: ________________________ ____________________________

First Name Last Name

Relationship: __________________________________________________________

Primary Phone Number(s): _______________________________________________

Cell Phone Home Phone

Secondary Contact: (In case Primary Contact cannot be reached)

Secondary Contact: ________________________ ____________________________

First Name Last Name

Relationship: __________________________________________________________

Primary Phone Number(s): _______________________________________________

Cell Phone Home Phone

� pennsylvania.;;:;_;;;;;, DEPARTMENT OF LABOR& INDUSTRY ... OFFICE OF EQUAL OPPORTUNITY

EQUAL OPPORTUNITY IS THE LAW

CIVIL RIGHTS STATEMENT

It is against the law for this recipient of Federal financial assistance to discriminate on the following basis:

Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and

Against any beneficiary of programs financially assisted under Title I of the Workforce Innovation and Opportunity Act (WIOA), on the basis of the beneficiary's citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIOA Title I-financially assisted program or activity.

The recipient must not discriminate in any of the following areas:

Deciding who will be admitted, or have access, to any WIOA Title I-financially assisted program or activity;

Providing opportunities in, or treating any person with regard to, such a program or activity; or

Making employment decisions in the administration of, or in connection with, such a program or activity.

WHAT TO DO IF YOU BELIEVE YOU HAVE EXPERIENCED DISCRIMINATION

If you think you have been subjected to discrimination under a WIOA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either:

The recipient's Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or

Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123, Washington, DC 20210.

If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Right Center (see address above).

If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with the CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient).

If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with the CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Financial Action.

OEO-18/18(ESP) REV01-16 SouthCentralWIOA_ 01

FOR INFORMATION OR TO FILE A COMPLAINT, CONTACT

JAMES J. KAYER jkayer@pa.gov DEPARTMENT OF LABOR & INDUSTRY OFFICE OF

EQUAL OPPORTUNITY 651 BOAS STREET, ROOM 1402

HARRISBURG, PENNSYLVANIA 17121-0750

717.787.1182 800.622.5422

TDD/TTY: 800.654.5984 FAX: 717.772.2321

Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

Issued: 7/30/14; Revised: 7/9/18

� pennsylvania� DEPARTMENT OF LABOR & INDUSTRY � OFFICE OF EQUAL OPPORTUNITY

STATEMENT OF RECEIPT

APPLICANT /PARTICIPANT

RIGHTS FORM

I hereby certify that I have received, read and understand my "Civil Rights" as an Applicant/Participant of the WIOA program and acknowledge so with my signature.

Applicant/Participant Signature Date Signed

Witnessed by WIOA Representative Date Witnessed

Witnessed at (name and address where the document was received, signed and dated).

Note: This document must be retained in the Applicant/Participant file.

Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

OE0-16 REV 01-16

SouthCentralWIOA_ 01 Issued: 7/30/14;Revised: 7/9/18

WIOA Title I Adult and Dislocated Worker Program GRIEVANCE AND APPEAL PROCEDURE

Confirmation of Receipt

I certify that:

_£_ I have read and understand the Grievance Procedure as stated herein.

_:!_,_ I have received a copy of the Grievance Procedure.

Participant's Signature Date

Participant's Name (print or type)

I certify that the herein named participant was given an explanation and a copy of the GRIEVANCE AND APPEAL PROCEDURE

Title I Staff Signature Date

Staff Name and Title (print or type)

SCWIOA 02 Issued: 7 /30/14

TANF APPLICATION/WIOA PRE-APPLICATION

APPL. DATE: ______ _ PIO# ______ _ WIOA □ TANF □ In-School □ Out of School □

Last Name: First Name: 55#: ---------- --------- ----------

Street: __________________ City: __________ Zip: ____ _

Documentation:

County: Phone: Cell: ------------ ---------- -----------

Basic Info.:

Gender: Male □ Female□ DOB: ------

Age: ----

Documentation:

Race: White □ Black/ African Am. D Hispanic/Latino D Am. Indian or Alaskan Native □ Asian □

Hawaiian Native or other Pacific Islander □ Do not wish to disclose D

Citizen: Yes □ No □ Documentation: SS#: Documentation: =-=-""""-"-��c...;;.;.;:;..;...;..;.. _______ _

Veteran: Yes □ No □ _D_o_cu_ m�e _n _ta_t _io_n_: _________ Separation Date: _______ _

Selective Service (Males 18 & Older}: Yes □ No □ N/ A □ =D-=o-=-c=um

:...:..:...=e

"-'n=ta=t=io"-'-n'-'-

: __________ _

Education Status: Not Attending-HS Graduate □ Not Attending-HS Dropout D In-School, HS □

In-School, Alternative School □ In-School, Post HS □ =D-=-o

...;;;.cu=m:...:..:...=e

.a..nt=a::..;:t.;..;:

io=-=-n

=-=-: _________ _

Highest Grade Completed: ___ _ School Attending/ Attended: ___________ _

Employment Status: Employed D 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 D

Homeless/Runaway: Yes □

School Dropout/risk of dropping out: Yes □

No□

No□

No□

Documentation:

Documentation:

Documentation:

Court involved or risk of court involved: Yes D No□ Documentation:

Basic Skills Deficient:

Individual with Disability:

Yes □

Yes □

No□ Documentation:

No□ Documentation:

Requires Additional Assistance to complete an educational program or to

secure and hold employment: Yes □ No□ Documentation: ____________ _

Incarcerated Parent(s):

Child of Migrant Worker:

Revised 10/2018 SCWDB

Yes D No□ Documentation:

Yes □ No□ Documentation:

-------------

-------------

Page 1

X X

PID# ---------

Income Eli2ibilitv: (Household Income & Family Size)

Family Member Relationship Age Occupation/Student Type/Source of 6 Month ' Income Amount

Family Size Total Total 6 Month Income

Proof of 6 month income: Documentation: ------------------------

Proof of Family Size: Documentation: _________________________ _

Receiving 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 is subject to review and verification and that I may have to provide documents to

support this application. I am also aware that I am subject 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: ____________ / _____________ __, ____ _

Signature Print Date

Signature of Parent/Guardian: ___________ __, __________ __, ____ _

(If applicant is under Signature

18 years old)

Print Date

Verifying Staff Person: ____________ __, ____________ __, ____ _

Signature Print Date

Supervisory/Secondary Reviewer: __________ _, ___________ __, ____ _

Revised 10/2018 SCWDB

Signature Title Date

Page 2

Self

APPENDIX C

WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) STATEMENT OF FAMILY SIZE/FAMILY INCOME

IDENTIFYING INFORMATION

Applicant's Name:------------------�-----------Last First Ml

Address: ________________________________ _

Participant ID: _____________ Application Date: ____________ _

To be completed by WIOA Applicant with staff assistance

For use in completing this form, the definitions of FAMILY and FAMILY INCOME can be found in this attachment.

Please provide information regarding the applicant's FAMILY as requested below.

FAMILY MEMBER'S NAME RELATIONSHIP TO APPLICANT FAMILY ME�BER INCOME (Last Six Months)

Total Number in Family: Total Income:

If applicable, please complete the following information for FAMILY MEMBERS not currently residing in the applicant's residence (see instructions).

NAME LOCATION REASON

I attest to the best of my knowledge that the information above is true and correct.

Signature of Applicant Date

CORROBORATING WITNESS - I attest to the best of my knowledge that the information is true and correct.

Name _____________ Signature ____________ Date ____ _

Address _______________ City _________ State __ Zip __ _

Telephone Number Relationship to Applicant ---------- ------------

Self

pennsylvania DEPARTMENT OF HUMAN SERVICES

TANF YOUTH DEVELOPMENT PROGRAM (TANF YDP)

Authorization for Release of Information

I hereby authorize and request the disclosure to the TANF YDP service provider any information

concerning education and training activities and any additional information involving eligibility

for myself. As a client in TANF YDP, I give permission to the TANF YDP service provider to

discuss my case with other agencies as needed to further my participation in TANF YDP. It is

understood that the information obtained will be used only for purposes directly related to the

participation and eligibility with the TANF YDP service provider.

Organization Name and Address:

Staff 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:

Harrisburg University of Science and Technology326 Market Street Harrisburg ,PA 17101

Danielle Schaufert

Electronic Signature Form (APP)

Due to the COVID-19 pandemic and the Governor’s mandated “stay at home” order, this form serves

as an electronic signature for program participants during this time of social distancing only. This

form is to be used for program enrollment such as the WIOA or TANF applications.

Please place an X on the lines below to indicate that you understand the following information.

I certify that the information provided for my WIOA Application is true to the best of my knowledge.

I certify that any information submitted by me on a self-attestation or self-certification form is true and correct.

I am also aware that the information I have provided is subject to review and verification, (including wage records and unemployment compensation information), and that I may have to provide documents to support this application.

I am also aware that I am subject 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.

I have received the civil rights and grievance procedures through email and I understand the

content and the steps to take if I feel I need to follow the grievance procedure.

By typing my name and date in the boxes below, I am authorizing it to be used as an electronic

signature verifying all of the above information is true.

Participant Name: Date:

Case Manager: Date:

SCWDB Form #F-11-4/20

Ref: Directive #D-8-4/20

Raspberry Pi Program Description:

In the Raspberry Pi Camp, students will engage in computer science topics utilizing the power of

programming. The Raspberry Pi Computer platform will enable the students to learn how to manipulate

aspects of a favorite video game called Minecraft through the use introductory programming

techniques. The best aspect of the camp is students will completely construct their own Raspberry Pi

computer to bring home. Through these activities, students will learn an introduction to computer

science and Python programming language to use with their new RPi Computer. At the end of the

session each student will take their computer home with them.

As the description above states the Raspberry Pi computer kit becomes the property of the student

upon completion of the course. Successful completion of the course consists of regular attendance in

the Canvas “Classroom” and submission of the Missions completed. The instructor will verify the

required attendance and submissions and will provide a certificate of completion to the student. IF the

student does not successfully complete the course, the Raspberry Pi kit must be returned to Harrisburg

University. Return information will be sent to student if this is necessary. If the kit is not returned the

student will be billed for the cost of the program.

Your signatures below indicate you understand the above statement and agree to the terms of the

statement.

_________________________________________________ _______________

Student signature date

_________________________________________________ _______________

Parent signature date