2025 Summer EYE Program Application Packet

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2025 Summer EYE Program Application Packet

This application should be reviewed and completed by youth with assistance from their referring organization and/or a parent/guardian (for participants under age 18). Enrollment in the EYE program is not complete until the EYE program staff receive, review, and approve the following: EYE Referral Form (completed and submitted by referring agency) EYE Application (completed and submitted by participant with the help of parent/guardian, case manager, etc.) All EYE participants will be required to submit the following forms in addition to their EYE application: The following forms will be collected and verified electronically by EvolvHR. Instructions on uploading these documents will be provided by email once EYE program staff have reviewed and confirmed a complete referral and application packet has been received.

Social Security Card VA-4 Form (Virginia Tax Form) Government issued ID/School ID I-9 Form Direct Deposit Agreement Voided Check or Proof of bank information (e.g., printout from bank showing the participant's name, bank name, and routing number) Federal W4 form MD State Tax Form W9 Form (WIOA participants only)

In-person intake sessions will be available if you are unable to provide these documents electronically. Will you need in-person assistance? *

NOTE: Please follow the provided calendars for deadlines related to the program. For questions, contact the EYE team at: DFSEYE@fairfaxcounty.gov

2025 EYE Program Information Form

Basic Information

Name: *

First

Last

Preferred Name (if different):

Pronouns:

Phone: *

Email: *

Home Address: *

City: *

Zip *

What organization referred you to EYE? *

Fairfax CYF
Fairfax NCS
WIOA
DARS Fairfax
DARS Manassas
DARS Alexandria
DARS Loudoun

DARS ID # (if applicable):

About You

What is your highest level of education? *

9th grade
10th grade
11th grade
HS Diploma or GED
Some College or Vocational Training

If some College or Vocational Training, please provide details:

Tell us about the activities you enjoy and skills you have: *

Have you worked or volunteered before? *

If yes, where?

If yes, what activities did you like doing at your work/volunteer site?

What activities did you NOT like at your work/volunteer site?

If applicable, select the following worksite accommodations that you will need at your worksite: *

Need written instructions
Need written materials in an accessible format
Need assistance getting around (moving from one area to another)
Need frequent breaks
Need extra time for tasks
Require an interpreter
Sensitive to surroundings
Use noise cancelling headphones
Modification of equipment or facilities
Need repeated instructions
None

Provide additional details on the items selected above or list other needs or accommodations not listed above that you need at a worksite (this will help us to identify the best worksite for you). Example: I need a Korean interpreter; I have a service animal; I am deaf and non-native English speaker, I need an ASL interpreter in Spanish) *

Provide us with the areas (ex. Annandale, Leesburg, Reston) and zip codes (ex. 22153, 22035, 22191) in Northern Virginia where you are able to work. While we cannot guarantee a site will be established in your preferred location, we will do our best to place you at a site close to your preferred area. *

How will you get to your worksite? (Check all that apply.) *

Bus/Metro
Walk/Bike
Drive yourself
Driven by family/guardian
Transportation coordinated by referral

Please provide any additional comments to assist us in making EYE the best experience possible for you: *

Rank your top career interests for the options below between 1 and 10 (1 being what interests you the most). Rankings are only allowed to be used once:

Automotive *

Retail *

Healthcare *

Technology *

Administrative/Office *

Construction (ages 18+) *

Finance/Accounting *

Other (Specify): *

Review the items below and let us know if you are interested or are not interested in the areas below. We will do our best to place you at a worksite that matches your preference:

Working with children *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Working with animals *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Working outdoors *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Sitting at a desk most of the day *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Entering data/information into a system or document *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Assisting people over the phone *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Assisting people in-person *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Packaging items *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Preparing food *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Creating flyers or presentations *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

Presenting to a group *

Yes, this is something I am interested in
No, I am not interested in this
I don’t know

2025 EYE Schedule

Training Sessions Virtual Orientation Training: One-hour session on June 9, 2025. Training 1 Session*: 3.5-hour In-Person Training on June 16 (DARS only), June 17 (CYF, NCS, KP, WIOA) June 18 (virtual make-up). Training 2 Session*: 3.5-hour In-Person Training June 23 (DARS only), June 24 (CYF, NCS, KP, WIOA). June 25 (virtual make-up) *One make-up session for each training is offered. Financial Literacy Session: Virtual 1.5-hour training on June 27th Work Experiences: June 30, 2025 – August 6, 2025 The EYE team will aim to have all participants placed in work experiences the week prior to June 30th however, placement may be delayed due to various factors (i.e., interest area, location, transportation, availability of position/site, etc.). To avoid delayed placement, we strongly encourage participants to be responsive to their EYE counselors and remain flexible when exploring different industry areas. Work experiences are scheduled between 8am-6pm, Monday through Friday. Exact hours may vary based on youth and employer availability. To ensure you receive the full benefits of EYE, youth must be available to work a minimum of 20 hours per week and a maximum of 30 hours per week for at least 5 of the 6 weeks. Youth must make every effort to attend all training sessions and may miss no more than five days of work once placed at their worksite. EYE Recognition Ceremony: August 7, 2025

Other schedule restrictions and details, including hours you are not available to work, summer school schedule, concerns, etc.: *

Signature of Youth: *

Clear Signature

Full Printed Name *

Date *

Signature Parent or Guardian (if youth is under age 18):

Clear Signature

Full Printed Name

Date

Uniform Consent to Exchange Information Form

Full Name: *

First

Last

I, (full name), understand that different agencies provide different services and benefits, and each requires specific information to deliver the best client experience. By signing this form, I am allowing Fairfax County Department of Family Services (DFS) – Educating Youth through Employment (EYE) Program to exchange the information with the selected agencies indicated below for the purpose of service planning, service coordination, payroll, and eligibility determination with the following entities:

I give permission for the Fairfax County Department of Family Services (DFS) - EYE Program and The SkillSource Group, Inc. to exchange information for the purpose of service planning, service coordination, and eligibility determination with the following entities: *

Workforce Innovation and Opportunity Act (WIOA)
Fairfax County Dept. of Family Services
Fairfax County Neighborhood & Community Services (NCS)
Medical Providers
Department of Rehabilitative Services (DARS)
Family
SkillSource Group, Inc.
Children, Youth and Families (CYF)
Other

If other, please specify:

The following information can be shared in writing, in meetings, via phone/text and/or through electronic means as it pertains to supporting my participation in the EYE Program. Check all that apply: *

I give permission for the selected agencies/organizations to share my medical information to include medical records, psychological and/or psychiatric records, mental health diagnosis, supports and/or accommodations.
I give permission for the selected agencies/organizations to share historical information such as employment, educational or criminal justice records.
I give the EYE Program permission to use my case record for review by any federal, county, or local government entities, including The SkillSource Group, Inc. for the sole purpose of ensuring the EYE Program is in compliance with laws, regulations and/or standards.
I understand that this consent is valid for one year from the date of signature by the consenting individual unless otherwise withdrawn.

I can withdraw this consent at any time by notifying the referring agency. I have the right to know what information has been shared, and why, when, and with whom. If requested, each agency will provide me this information.

Name of individual completing form: *

Relationship to individual: *

Self
Parent/Family
Guardian

Full Printed Name of EYE Participant: *

Signature of EYE Participant (or parent/guardian if under 18): *

Clear Signature

Date: *

Emergency Contact and Medical Release Form

General Information

First Name: *

Middle Initial:

Last Name: *

Date of Birth: *

Home Phone: *

Cell Phone: *

Address: *

City: *

Zip: *

Health Insurance (if applicable): *

Primary Physician or Clinic: *

Allergies (including Medications): *

Medical conditions that should be noted: *

Emergency Contacts

Name: *

Phone: *

Participant Signature: *

Clear Signature

Full Printed Name *

Date: *

Parent Signature (for participants under age 18):

Clear Signature

Full Printed Name

Date:

Payroll Payment Process Agreement

Full Name: *

First

Last

I, (full name), acknowledge the following: I understand that as an EYE participant, I will be placed with an employer and receive taxable income in the form of hourly pay for my participation. I understand that I am responsible for submitting a timesheet every two weeks and will receive payment within four weeks of the scheduled date of timesheet submission. I understand that if my timesheet is submitted late, it will delay when I receive payment. I understand that timesheets must be completed and signed by my worksite supervisor and myself to be processed. I understand that the income I receive is taxable. (Note: NCS, CYF, DARS, and Kaiser Permanente participants will receive a W2, WIOA participants will receive a 1099 form.)

Participant Signature: *

Clear Signature

Full Printed Name *

Date: *

Parent Signature (for participants under age 18):

Clear Signature

Full Printed Name

Date:

Fairfax County Government Photo and Video Release Form

This form is optional and will not impact participation in EYE.

I give permission for (name of participant):

First

Last

to be photographed and/or videotaped by Fairfax County government representatives. I acknowledge and agree that the photographs and videos may be edited and used for noncommercial purposes as desired in any Fairfax County government print, electronic, or social media. I understand that photographs and videos become the property of Fairfax County without compensation to me. I also understand that any photographs and videos will be subject to the Virginia Freedom of Information Act.

Signature: *

Clear Signature

Date: *

Parent/Guardian Signature (if under age 18):

Clear Signature

Date:

Program: Educating Youth through Employment (EYE) Dates: June 2025 - August 2025

Dates: June 2025 to August 2025

Job Readiness Assessment – Before EYE Participation

Please complete the following so we can determine what areas to focus on during job readiness trainings and assess the job readiness skills you have developed throughout your participation this summer.

Job Exploration Counseling Questions

I know what a career pathway is. *

I can list at least two jobs within a career that interests me. *

If yes, enter jobs that interests you:

Work-Based Learning Experiences Questions

I can list two common workplace rules. *

If yes, enter common workplace rules:

I can list at least one area I want to build my work skills: *

If yes, enter areas you want to build my work skills:

Pronouns: Last you

Counseling on Postsecondary Education and Training Options Questions

I can list two ways college/training is different from high school. *

If yes, enter ways college/training is different from high school:

I can list two jobs I am interested in that require training/education beyond high school. *

If yes, enter jobs you are interested in that require training/education beyond high school:

Workplace Readiness Training Survey Questions

I can list two examples of where and/or how to search for work. *

If yes, enter examples of where and/or how to search for work:

I know one way to help me save my money. *

If yes, enter one way to help you save my money:

Instruction in Self-Advocacy Survey Questions

I can list two of my strengths. *

If yes, enter two of your strengths:

I can list two of my support needs. *

If yes, enter two of your support needs: