2026 SYEP Pre-Employment Application

2026 SYEP Pre-Employment Application
Please be advised that completing this application does not guarantee employment with the program. Space is limited. Applicants selected for an employment interview will be notified by email. Applicants must qualify based on income standards.
Name*

First NameMiddle InitalLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Birth Date*

MonthDayYear
Date
Current Date

MonthDayYear
Date
Age
Email*
example@example.com
School Currently Attending*
Grade*
Did you participate in the 2025 Summer Youth Employment Program*
If yes, where did you work
Did you successfully complete the program?
If no, why didn't you complete the program
Referring Agency
Referring Agency's Contact Person
Please have a parent or guardian complete the section below. If you are 18 years of age or older and live independently, please complete this section yourself. Please check all sections of benefits listed below that the youth listed on this application is currently receiving. All areas checked will be verified with the Chemung County Department of Social Services to determine program eligibility.
Temporary Cash Assistance caseMedicaid caseSNAP caseHEAP caseMy child does not receive any of the above services. Therefore, I understand this applicant will need to be verified by household income.
YesNo
YesNo
Parent/Grantee Signature By signing you are authorizing and releasing the Youth Bureau to verify with the Department of Social Services that your child is in receipt of the benefits selected above. *

Clear
I understand that this consent may be withdrawn by me at any time (which must be done in writing) and shall expire one year following the date of signature, or at case closing.
Name of Parent Signature*
Youth Signature*

Clear
Name of Youth Signature*
Click the Submit Button to preview and submit your application.

PLEASE NOTE! - If you want a record of your application you must print before submitting. You will not have another opportunity to view or print your application after submission.
FA/SN200%Income
Should be Empty: