2025 Summer EYE Program Referral Form - Virginia Career Works Northern Region

To be completed by the individual from the sponsoring organization that directly works with the youth. It is recommended the youth be available to assist in answering questions if needed. Important information to verify before completing the application: EYE work experiences are for youth ages 16-24. Review the 2025 EYE Schedule below with the youth and parent/guardian to ensure they are available for the dates provided Referral and application deadlines: NCS/CYF/WIOA: April 28, 2025 DARS: April 21, 2025

Applicant’s Information

First Name *

Last Name *

Preferred Name

Age *

Date of Birth *

Gender *

Pronouns *

Phone *

Email *

coach? Contact work?

County/City of Residence *

If other, specify here:

Sponsoring Organization: *

DARS Applicant ID (if applicable):

Referral Contact Information

Referral Contact Name *

First

Last

Relationship to Applicant *

Organization *

Phone *

Email *

How long has the youth been participating with your organization? *

How often do you communicate/interact with the youth? *

Why do you think this youth would be a good fit for the EYE program? *

Other Contact Information

Please provide details for other individuals that will be supporting the youth throughout their EYE participation, including parent/legal guardian, job coach, other case managers. Please note, the consent form included with the application MUST list these individuals.

Contact Name

Contact Relationship

Contact Email

Contact Phone

Worksite Placement Information

Has a worksite already been created? *

Yes
No

If a worksite is not already created, do you know of any sites that might match your youth’s needs and interests? *

What are some needs that we should consider when matching your youth? Select all that apply. *

Please provide additional details on the items selected above or any other needs the youth may have to help us identify the best worksite for the youth (Ex. type of interpreter needed, types of accommodations, etc.):

Will the youth need a job coach? (Note: This must be provided by the referring organization.) *

Yes
No

If youth does need a job coach, what percentage of support will they receive?

10-25%
25-50%
50-75%
75-100%

If the coach has already been assigned, please provide their information under “Other Contact Information."

What places/surroundings would NOT be a good fit for the youth? Select all that apply *

If other, specify here:

Would the youth be a good fit for remote work? *

Yes
No

Does the youth have any prior work experience or skills that should be considered? (ex. MS Office, activities, etc.) *

How will the youth get to their worksite? (Check all that apply) *

Please provide any additional comments or suggestions to support a successful work experience for this youth *

2025 EYE Schedule

The Summer 2025 EYE Program includes two half-day trainings and 6 weeks of work experience. To ensure the youth receives the full benefits of EYE, they 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 can miss no more than five days of work once placed at their worksite. Contact DFSEYE@fairfaxcounty.gov for questions on the schedule. Training Sessions Training 1 Session (youth will attend one of the following sessions): June 16 at 9am-12:30pm (DARS only) June 17 at 9am-12:30pm June 18 at 9am-12:30pm (virtual) Training 2 Session* (youth will attend one of the following sessions): June 23 at 9am-12:30pm (DARS only) June 24 at 9am-12:30pm June 25 at 9am-12:30pm (virtual) Financial Literacy: June 27 10-11:30am, virtual via Zoom Work Experience Details To ensure youth receive the full benefits of their work experience, youth will need to participate in work experience a minimum of 20 hours per week over 6 weeks. Work experiences are scheduled between 8am-6pm, Monday through Friday. Exact hours may vary based on youth and employer availability. Work experiences are scheduled between the hours of 8am-6pm, Monday through Friday.

Check the days below that the youth is NOT able to participate:

Other schedule restrictions and details

Signature of Referring Individual *

Clear Signature

Date *