Summer Youth Employment Program Cover Sheet- Hamilton County Job & Family Services Page 2
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4Instructions for completing Application for TANF Summer Employment Program for Youth 2014
1. A Parent or Guardian must complete this application if the person who will participate in the TANF Summer
Employment Program for Youth is a minor child. A minor child is an individual who:
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Has not attained 18 years of age; or has not attained 19 years of age and is a full-time student in a
secondary school (or in the equivalent of vocational or technical training).
2. All household members must be listed on the application
3. Monthly income must be listed and verification provided for Applicant and Applicant’s family members.
4. All questions must be answered (do not leave blank spaces).
5. Print all written responses.
Section I – Complete the Demographic Information
Parent or Guardian Name: Include first and last name
Youth Name: Include first and last name of the youth applying for the summer program
Present address: Include full address
Present Phone: Home landline or cell number
Alternate Phone Number: Second phone number if available or a message phone number
Email Address: Parents or Adult (18yrs) applicant email address to receive SYEP related communication
Section II – List All Household members
1. Name:
List name of youth who is applying for the summer program first
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List parent or guardian’s name second
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List all other household members below on their own line
2. Relationship to Youth:
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List relationship of each household member to the youth
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“Self” is written in the relationship field for the youth applying for the summer program
3. Source of Monthly Income:
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List earned and unearned income received by each household member
4. Monthly Amount of income:
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Monthly amount of gross income
Section III – Read and Answer All Questions
Check yes or no for each response. If “yes” response is made for any question, use the box provided
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to write the name of the person and the condition or explanation.
For example, if yes was answered to the question about pregnancy, write the name of the household
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member who is pregnant and the due date.
Section IV – Read and Sign the Application
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This allows HCJFS to share information about you with the providers ResCare LLC. & CAA for any purpose
relating to the program. The application signature will serve as a release of information.
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The parent or guardian and the youth must sign and date the application
For HCJFS Use Only:
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WFD-Eligibility Worker will complete this section to indicate if Application approval or denial.
Note to Providers: If applicable, please review the application with Youth to ensure all questions have an answer,
before submitting it to HCJFS. Incomplete applications will be denied.
HCJFS 3124 (REV. 5-14)
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