2020-2021 Learn & Earn: Virtual

2020-2021 Learn & Earn: Virtual - Session 1

Application Deadline: Friday, October 9th, 2020
The Learn & Earn Program includes 20 hours of teaching life and job skills through workshops after school. Students that successfully complete the program will receive a payment incentive for attending and participating.
Name *

First Name Middle Inital Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email
example@example.com
Birth Date *

Month Day Year
Date
Current Date

Month Day Year
Date
Age
Cell Phone *
Home Phone
Gender *
Ethnicity *

White Black Hispanic American Indian Asian Bi-racial
School Currently Attending *

Elmira High School Edison High School Horseheads High School
Grade *
What time are you done with school?

: Hour Minutes AM/PM Option
Parent/Guardian Name

First Name Last Name
Parent/Guardian Phone Number
Address same as above
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you have any pre-scheduled appointments or prior commitments between October 19th - November 19th? If so, please list the dates:
Examples: sports teams, clubs, etc.
Please Note: Program workshops will take place Monday through Friday from 3:00-4:00pm. If you do not attend school, you will not be able to participate in Learn and Earn on that day. Attendance and participation are a mandatory component of this program and will be monitored daily. *

Click here that you understand that failure to meet the attendance and participation requirements will result in not receiving a stipend
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.
Family Assistance / Safety Net Medicaid SNAP HEAP SSI
I consent that the youth listed on this application may be included in any photograph taken while participating in the Summer Youth Employment Program and understand that the photo may be used for publication or publicity purposes. *

Yes No
Parent Signature *

Clear
Name of Parent Signature *
Youth Signature *

Clear
Name of Youth Signature *
Contact: Laura Zurn, Youth Program Coordinator
Chemung County Youth Bureau & Recreational Services
599 Harris Hill Road
Elmira, NY 14903
Phone: (607) 737-2907
Select the "Click Here To Submit" Button to review your application and then click the “Submit” Button.

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.
Should be Empty:

2020-2021 Learn & Earn: Virtual - Session 1