Form Wtw 16 - Grant-Based On-The-Job Training Participation: Voluntary Consent Form Page 2
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2GRANT-BASED ON-THE-JOB TRAINING ASSIGNMENT
EMPLOYER’S NAME:
EMPLOYER’S ADDRESS:
SUPERVISOR’S NAME
SUPERVISOR’S PHONE NUMBER
LENGTH OF ASSIGNMENT:
DAILY WORK HOURS:
TOTAL HOURS OF WORK ASSIGNED PER WEEK:
HOURLY STARTING WAGE:
From ____________ to____________
From __________ to__________
ggggg
Amount that the CWD will pay to my employer: $_______. The CWD will subtract this money from my grant, or if my grant is
not enough, from the grant savings to the CWD caused by my wages.
I agree to tell my Welfare-to-Work worker of any changes to my work schedule as soon as possible, but no later than five (5)
days after the change.
I understand that the employer will provide the following benefits:
None
Paid Holidays
Health Insurance
Dental Insurance Coverage
Sick Leave
Vacation
Others ______________
CERTIFICATION
I understand the purpose of the grant-based OJT assignment is to give me work skills and help me find a job. I have read this
form and its contents have been explained to me. I know that I must meet all my responsibilities as a Welfare-to-Work
participant. I understand that I can ask my Welfare-to-Work worker if I have any questions.
I understand that I must tell my Welfare-to-Work worker right away of changes in my need for Welfare-to-Work supportive
services or if I no longer need them. If I do not report the changes in advance, Welfare-to-Work may not be able to pay for
them. I understand that if Welfare-to-Work pays for supportive services that are more than what I need to participate in
Welfare-to-Work, I will have to pay Welfare-to-Work back.
I understand that if this is my first Welfare-to-Work activity and I want to ask for a change or be assigned to another activity,
I have 30 days from the beginning date of my first activity to contact my worker.
If this is not my first activity, I understand that if I want to ask for changes to my Welfare-to-Work Plan, I have three (3) working
days after my plan was completed or my plan was changed to contact my worker.
I do not wish to participate in a grant-based OJT assignment at this time.
PARTICIPANT'S SIGNATURE
DATE
I want to volunteer for a grant-based OJT assignment. I have read (or had read to me) and understand the information
provided above and have received a signed copy of this form.
PARTICIPANT'S SIGNATURE
DATE
WELFARE TO WORK WORKER'S SIGNATURE
PHONE
DATE
You have the right to ask for a state hearing if you disagree with any of the decisions made by the county about participating in
Welfare-to-Work.
WTW 16 (12/05) GRANT-BASED OJT VOLUNTARY CONSENT (2 OF 2) - REQUIRED FORM - SUBSTITUTE PERMITTED
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