ELP 22-23 Application

2022-2023 Emerging Leaders Program (ELP) Application
ELP is a FREE program for low-income high school seniors that are no older than 18 years of age at East Allegheny, McKeesport Area, Penn Hills, West Mifflin Area, and Woodland Hills High Schools. It provides students guidance in planning and preparing for life after high school.
- ELP participants will attend a session once a week for a 40 minute period during the school day. Staff also support students by meeting with them on one one thorughout each month, also during school hours.
- Students receive help with post-graduation goals, career planning, and college/post secondary training preparation.
- Features career exploration, job shadowing, job/school/training searches, field trips to various job sites and schools, and more.
- Students will earn a modest incentive periodically based on participation and goal completion throughout the school year and post-graduation.
The following information and requested supporting documents are required to determine eligibility for the student to participate in the Emerging Leaders Program. Please print all information clearly. Failure to complete this application correctly and fully could result in the student not being accepted into the Emerging Leaders Program. All information will be kept confidential .All releases MUST be signed by the appropriate persons.
*By clicking the "Save" button you'll be able to save and return to the application using the original link you received*

Eligibility Requirements

To participate in the Emerging Leaders Program, the youth (and their legal spouse and/ or children if applicable) must provide verification that their personal monthly gross earned income does not exceed 235% of the FPIG
* Household Income Eligibility Standars subject to change

* Entire family income (including youth's parental income) will also be considered in regards to determining acceptance
What do we need from you?
- Completed ELP application
- A copy of student's birth certificate
- A copy of student's signed social security card
- A copy of the student's most recent report card
- Proof of student income if student is employed (such as MOST RECENT pay stub)

Emerging Leaders Program

CONTACT INFORMATION
Mother's/Legal Guardian's Name:

First Name Last Name
Mother's/Legal Guardian's Maiden Name:
Mother's/Legal Guardian's Address:

Street Address

APT

City State / Province

Postal / Zip Code
Is student living with Mother/Legal Guardian?

Yes No
Is English the primary language for the Mother/Guardian?

Yes No
Mother's/Legal Guardian's Home Phone:

Area Code Phone Number
Mother's/Legal Guardian's Cell Phone:

Area Code Phone Number
Mother's/Legal Guardian's Work Phone:

Area Code Phone Number
Mother's/Legal Guardian's Email Address:
example@example.com
Mother's/Legal Guardian's Birthdate:

Month Day Year
Date
Mother's/Legal Guardian's Social Security #:
Father's/Legal Guardian's Name:

First Name Last Name
Father's/Legal Guardian's Address:

Street Address

APT

City State / Province

Postal / Zip Code
Is student living with Father/Legal Guardian?

Yes No
Is English the primary language for Father/Guardian?

Yes No
Father's/Legal Guardian's Home Phone:

Area Code Phone Number
Father's/Legal Guardian's Cell Phone:

Area Code Phone Number
Father's/Legal Guardian's Work Phone:

Area Code Phone Number
Father's/Legal Guardian's Email Address:
example@example.com
Father's/Legal Guardian's Birthdate:

Month Day Year
Date
Father's/Legal Guardian's Social Security #:
Emergency Contact (OTHER THAN PARENT/GUARDIAN): *

First Name Last Name
Relationship to Applicant: *
Contact Phone: *

Area Code Phone Number

Emerging Leaders Program

PARENTAL CONSENT FORM
I grant permission for my son/daughter: *

First Name Last Name
To participate in all scheduled activities of the Emerging Leaders Program. In addition, I grant authorization for my son/daughter to be taken off-site by the Human Services Center Corporation staff for field trips and other special events. I release the Human Services Center Corporation and its insurers from any and all liability, claims, causes of action, damages, cost expenses or demands of any kind which may arise in connection with his or her participation in the activities of the Program.

Occasionally, Emerging Leaders Program staff members wish to photograph, videotape, or otherwise record the activities of Program participants for the purpose of recording, promotions, and reporting outcomes of the Program. We sometimes provide local newspapers with information about the Emerging Leaders Program participants, such as the student’s name, grade, school district, and what the student has done during the Program.

I hereby give permission for my child to be photographed, videotaped, recorded on a Zoom session or otherwise have their image or voice recorded, in connection with the Emerging Leaders Program. I allow the Human Services Center Corporation to use the photographed, videotaped, and/or recorded materials in any publications, promotional materials, reports, social media, websites, CD’s, DVD’s, other media for publicity, reporting purposes, or in any other non-commercial manner that it chooses. I hereby waive and release any rights that I may have to the said videotaped, recorded, and/or photographed materials.

I further grant permission for the Human Services Center Corporation to provide local media and foundations with information about my child. Moreover, I release the Human Services Center Corporation and its insurers from any and all liability, claims, causes of action, damages, cost expenses or demands of any kind which may arise in connection with his or her participation in the activities of this after-school program.
Name of Student: *

First Name Last Name
Signature of Student: *

Clear
Date *

Month Day Year
Date
Signature of Parent/Guardian: *

Clear
Date *

Month Day Year
Date

Emerging Leaders Program

PERMISSION FOR MEDICAL TREATMENT AND RELEASE
I wish to have my child: *

First Name Last Name
Participate in the Emerging Leaders Program. I understand that there are risks and hazards, in addition to benefits, associated with my child’s participation. I, on behalf of myself, my child, our heirs, executors, administrators, and other personal representatives, do hereby irreversibly and unconditionally remise, release, settle, compromise and forever discharge any and all manner of suits, actions, causes of action, damages and claims, known and unknown, that I or my child, have or may have against the Emerging Leaders Program and the Human Services Center Corporation arising from or connected with my child’s participation in the Program, including the securing of medical treatment for my child.

I give permission for the Emerging Leaders Program and Human Services Center Corporation to secure medical treatment for my child in the event that such treatment is required during my child’s participation in the Program. I will be financially responsible for the cost of such treatment. The Commonwealth of Pennsylvania’s laws apply to this Permission for Medical Treatment and Release. This release will remain valid and binding from the beginning to the end of the Program.

I have read and understand the terms of this release. I sign this document voluntarily, knowing that I am legally bound by it. I am over eighteen years of age, and competent to sign this document. I release the Human Services Center Corporation and its insurers from any and all liability, claims, causes of action, damages, cost expenses or demands of any kind which may arise in connection with his or her participation in the activities of this program.
Name of Student: *

First Name Last Name
Signature of Student: *

Clear
Date: *

Month Day Year
Date
Signature of Parent/Guardian: *

Clear
Date: *

Month Day Year
Date

Emerging Leaders Program

AUTHORIZATION FOR SHARED INFORMATION
I hereby give permission to the Human Services Center Corporation to share information on my child: *

First Name Last Name
With funders, places of employment, school district personnel, emergency care providers, counselors, medical professionals, mental health therapists, and other human service agencies on an as-needed basis. All information will be kept strictly confidential.

I authorize and instruct the Emerging Leaders Program to obtain my son/daughter’s report card, attendance records, work records, assessment tests including but not limited to the Keystone, PSSA, Terra Nova, 4Sight, DIBELS, OLSAT test scores, and diploma and/or final transcript for the purpose of tracking academic and overall progress. In addition, I do hereby approve and instruct my child’s school and/or district to release to the Human Services Center Corporation any pertinent and/or necessary behavioral reports of my son/daughter for the purpose of mandatory tracking and reporting.

I release the Human Services Center Corporation and its insurers from any and all liability, claims, causes of action, damages, cost expenses or demands of any kind which may arise in connection with his or her participation in the activities of the Program.
Signature of Student: *

Clear
Date: *

Month Day Year
Date
Signature of Parent/Guardian: *

Clear
Date: *

Month Day Year
Date
Name of Student: *

First Name Last Name
Name of School and District Attended during 2021-2022 School Year: *
Name of School and District Attending during 2022-2023 School Year: *

Emerging Leaders Program

APPLICANT 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, 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 the release of this information for verification and reporting purposes and understand that it be used to determine eligibility.
Signature of Applicant: *

Clear
Date: *

Month Day Year
Date
Signature of Parent or Guardian: *

Clear
Date: *

Month Day Year
Date
Authorized Staff Certification

I have reviewed all of the above information supplied by the applicant and have found it to be a reasonable representation of the individual's status at the time of the interview.
Signature of Certifier:

Clear
Date:

Month Day Year
Date

Partner4Work

Media RELEASE FORM
I hereby give Partner4Work permission, with respect to any photographs, images, or voice recordings that it, through its contractor employees or agents, takes of me or in which I may be included with others:

(a) to use, re-use, publish, and republish the same, in whole or images, individually or in conjunction with other photographs, in any medium for the purpose of promoting Partner4Work or its funded programs.

(b) to use my name in conjunction therewith, if Partner4Work, through its contractor employees or agents, so chooses.
Permission
OR
I hereby deny Partner4Work permission to use, re-use, publish, or republish photographs, images, or voice recordings taken of me or in which I may be included with others.
Deny
UNDER 18 YEARS OF AGE
Applicant Signature: *

Clear
Name of Applicant: *

First Name Last Name
Signature of Parent/Guardian: *

Clear
Name of Parent/Guardian: *

First Name Last Name
18 YEARS OF AGE OR OLDER
Applicant Signature: *

Clear
Name of Applicant: *

First Name Last Name
Date: *

Month Day Year
Date
Home Address: *

Street Address

APT

City State / Province

Postal / Zip Code
Telephone #: *

Area Code Phone Number
Contractor Witness:
Signature:

Clear
Name:

First Name Last Name

PARTNER4WORK

The Workforce Development Board for the Pittsburgh Area
Youth Workforce Development Program Signature Page

Instructions: Please read the statements below and acknowledge by signing in the appropriate places. If you are under 18, you must obtain the signature of a parent or guardian. Note: This document must be retained in the Applicant/Participant file.256

GRIEVANCE STATEMENT

PARTNER4WORK has established and maintains a grievance procedure for grievances or complaints about its programs and activities. All applicants and participants of the employment and training programs offered by Parter4Work are entitled to take advantage of this procedure. Initially you should attempt to resolve your complaint informally at the agency/department/training institution where you are placed. If the complaint cannot be resolved at this level to your satisfaction, you may file a complaint in writing summarizing your issue to:

Program Evaluation Manager

Partner4Work

Centre City Tower, Suite 2600

650 Smithfield St., Pittsburgh PA 15222

Program Evaluation Manager reviews and/or investigates the complaint in an attempt to reach an informal resolution. If an informal resolution cannot be reached, a formal hearing will be provided within 30 days of original filing date. A written decision will be rendered to all parties within 30 days of hearing.

I have read and understand the above statement and acknowledge so with my signature.
Applicant/Participant Signature: *

Clear
Date: *

Month Day Year
Date
Parent or Guardian Signature: *

Clear
Date: *

Month Day Year
Date
Staff Member as Witness:

Clear
Date:

Month Day Year
Date
EQUAL OPPORTUNITY IS THE LAW

CIVIL RIGHTS STATEMENT

Partner4Work and its agents, partners, and affiliates do not discriminate, on the basis of race, color, religion, religious creed, sex, sexual orientation, gender identity, national origin, ancestry, marital status, age or non-job-related disability as required by federal, state, and local law.

Here is some information about YOUR CIVIL RIGHTS UNDER FEDERAL LAW. Partner4Work, is prohibited from discriminating on the grounds of race, color, religion, sex, national origin, age, disability, political affiliation or belief, and, for beneficiaries only, citizenship, or participation in federally funded programs, as amended in admission or access to, opportunity or treatment, in, or employment in the administration of or in connection with any federally funded activity. If you think that you have been subjected to discrimination under a federally funded program or activity, you may file a complaint within 180-days from the date of the alleged violation with the Department of Labor and Industry’s (L&I) Office of Affirmative Action (OAA), or you may file a complaint directly with the Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue, N. W., Room N-4123, Washington, DC 20210. If you elect to file your complaint with the Office of Affirmative Action, you must wait until the Office of Affirmative Action issues a decision or until 60-days have passed. Whichever is sooner, before filing with the CRC (see above address). If the OAA has not provided you with a written decision within 60-days of filing of the complaint, you need not wait for a decision to be issued, but may file a complaint with CRC within 30-days of the expiration of the 60-day period. If you are dissatisfied with the OAA’s resolution of your complaint, you may file a complaint with CRC. Such a complaint should be filed within 30-days of the date you receive notice of the OAA’s proposed resolution. If you have any questions, regarding YOUR CIVIL RIGHTS, or to file a discrimination complaint, please contact: The Department of Labor and Industry, Office of Equal Opportunity – Room 514, Labor and Industry Building, Seventh and Forster Streets, Harrisburg, Pennsylvania 17120. Or call (717) 787-1182, 1-800-622-5422, TDD 1-800-654-5984. Also, a complaint can be filed by phone or in person at the local office. U.S. Equal Employment Opportunity Commission, 1000 Liberty Ave, Suite 1112, Pittsburgh, PA 15222. For general inquiries or to begin the process of filing a complaint of discrimination, call 1-800-669-4000. All complaints will be handled confidentially.

Statement of Receipt: I hereby Certify that I have received, read and understand my rights under law and acknowledge this with my signature.
Signature of Participant: *

Clear
Date: *

Month Day Year
Date
Witnessed by TANF Representative:

Clear
Date:

Month Day Year
Date

PARTNER4WORK

The Workforce Development Board for the Pittsburgh Area
Witnessed at (name and address where the document was received, signed, and dated): *

Street Address

APT

City State / Province

Postal / Zip Code
Release of Information - Participant Consent Form
Participant Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Social Security Number #: *
(Ex. 555-55-5555)
ISY/OSY Service Provider:
Provider Address:

Street Address

A

City State / Province
I hereby authorize HSCC (TANF Service Provider) as well as Partner4Work to request and/or disclose my personal data (including name, address, social security number, status in the program) Allegheny County Assistance Office, Allegheny County Department of Human Services, training institutions/schools or prospective employers, as deemed as necessary for my participation in a TANF/WIOA program. I realize this information will be shared in the interest of providing the most appropriate services for me. I also give permission to including but not limited to; Allegheny County Assistance Office, Allegheny County Department of Human Services, training institutions/schools, or current, past, and prospective employers as it relates to my participation in a TANF/WIOA program; to release the following information to HSCC (TANF Service Provider) as well as Partner4Work:

I have read this form, and/or had it explained to me and I understand its contents.

I release HSCC (TANF Service Provider), from all legal responsibility or liability for disclosure of the above information to the extent that the information was used for its stated purpose. I understand the release of my personal data will be used for my benefit, for program tracking and reporting purposes and will not be shared with any entity for any other purpose.
Signature of Participant: *

Clear
Date: *

Month Day Year
Date
Parent or Guardian Signature: *

Clear
Date: *

Month Day Year
Date
Staff Name:

First Name Last Name
Staff Signature:

Clear
Date:

Month Day Year
Date
Note: This document must be retained in the Applicant/Participant file.

Emerging Leaders Program

Supporting Documents
If possible, please upload a photo of the student's:

-Signed Social Security Card
-Birth Certificate

OR

-Passport

AND

-Most Recent Pay Stub (if working)

*If necessary, documents can be uploaded later, but your application will considered incomplete without these documents.
Student's Social Security Card (signed):

Browse Files

Cancel of
Student's Birth Certificate:

Browse Files

Cancel of
Student's Most Recent Pay Stub (if working):

Browse Files

Cancel of
Student's Passport:

Browse Files

Cancel of

Emerging Leaders Program

Submissions Page
**Please double check that you filled

out all possible fields before submission**
Student Signature: *

Clear
Please verify that you are human: *
Should be Empty:

	First and Last Name	Relationship	Income for Last 6 Months	Source of Income (Employer wages should be GROSS wages)
Student
Household Member
Household Member
Household Member
Household Member
Household Member
Household Member
Household Member

2022-2023 Emerging Leaders Program (ELP) Application

Eligibility Requirements

What do we need from you?

2022-2023 Emerging Leaders Program (ELP) Application

Emerging Leaders Program

Emerging Leaders Program

Emerging Leaders Program

Emerging Leaders Program

Emerging Leaders Program

Emerging Leaders Program

Emerging Leaders Program

Partner4Work

PARTNER4WORK

PARTNER4WORK

Emerging Leaders Program

Emerging Leaders Program