YOUTH REGISTRATION FORM

2023

If you have any questions concerning this registration form or general questions about the Summer Youth Works Program, please contact Paige Evans at

478-272-5546 or email membershipservices@dublin-georgia.com.

First Name *

Last Name *

Address *

City *

State *

Zip *

Cell Phone Number *

Date of Birth * +

Email Address *

Re-type Email Address *

Gender *

Male

Female

T-Shirt Size *

Primary Language *

English

Spanish

Bilingual

Other

Emergency Contact First and Last Name *

Emergency Contact Relation to Applicant *

Emergency Contact Phone Number *

Emergency Contact Email *

Emergency Contact Address *

Emergency Contact City *

Emergency Contact Zip Code *

Emergency Contact Cell Phone Number *

Do you have any health conditions or health related concerns or any allergies? *

In order to participate, you must be at least 16 years of age. Will you be at least 16 years of age on or before June 5, 2023? *

Yes

No

You must have reliable transportation in order to get to and from the jobsite. Do you have reliable transportation? *

Yes

No

School *

Do you have any scheduled vacation plans this summer? *

Yes

No

If yes, vacation start date +

If yes, vacation end date +

Please read the below statements and sign off that they have been reviewed and agreed upon. *

I understand that I must interview for a position with a participating business on May 10th from 3:00 - 5:00 in the McGrath Keen Sr. Conference Center.

I understand that June 5th -9th will be soft skills training and that it is mandatory I am present the entire time from 8am-12pm.

I understand that I may be required to submit to a drug screening depending on the policies of my particular employer.

I understand that my employer may require my criminal history be reviewed prior to employment.

I understand that I will be paid at least $8.00 per hour and work at least 32 hours each week.

I understand that I must attend the Summer Youth Works Wrap-Up Ceremony on July 28th.

Have you ever been convicted of a felony or any offense involving theft? *

Yes

No

If yes, select one of the following:

Violent

Non violent

Do you have a valid drivers license or state ID? *

Yes

No

Are you willing to participate in an initial drug screening? *

Yes

No

Are you willing to work with animals? *

Yes

No

1st Choice: Type of summer work interested in *

2nd Choice: Type of summer work interested in *

Can you work outside? *

Any allergies? If so please list. *

**If selected, we can not guarantee that you will be placed in your desired work interest. We will make every effort to place you in a comparable position.

**Interviews will be scheduled with each business on Thursday, April 19th at in the McGrath Keen, Sr. Conference Center at the Chamber of Commerce. Interviews will be from 9:00AM to 11:00AM on that date. Please see the contact person at your school for more details.