Dear Prospective Oakland Youth Engaged! Participant: Thank you for your interest in the Oakland Youth Engaged program (funded by OFCY). For those interested in being a part of an experience of a lifetime, you will find the next few pages as a crucial step in your journey. Get ready to be exposed to new and exciting opportunities, building in leadership skills, creating a personal education or career plan, gain employment experience and participate in community engagement projects.

SUMMER PROGRAM

Workshops: September 19th – October 26th & Internships (for qualified participants): November through mid December

Must be 14-18 yrs old and an Oakland resident

All youth are welcome to apply!

¡Oakland Youth Engaged! selected participants must commit to completing the program and all program activities. Participants will be engaged in changing their communities, their beautiful city, and themselves by attending workshops to learn various life and job skills, and participating in community events. Youth who complete all activities may be placed in 6-8 week job internships with various nonprofit organizations, government agencies, and local businesses. Stipends are given to participants based on attendance and participation.

Steps Into OYE Are You On Your Way?

Learn More Details

Submit

Application

Meet with a staff person

Start OYE!

Drop by, Call, or Email: Douglas Phenix, 510-535-6943 dphenix@unitycouncil.org, OR Ashley Nelson, 510-535-7179,

anelson@unitycouncil.org Front Desk: 510-535-6101

Unity Council is at: 1900 Fruitvale Ave, Ste 2A, Oakland, CA 94601

Along with your app, bring: Photo ID (see below) OUSD Work Permit

If you need help getting these items, see OYE Staff for help!

Schedule a time to

meet with a counselor and

complete a short interview

First day of program will

be September

14th 4:30-6:30pm

Were You Referred By Anyone? Were you referred to apply to our program? If so, list their info below!

Name:__________________________ Position: ______________________ Agency: __________________ Phone or email:_______________________

Questions/Concerns? Contact: Douglas Phenix, email: dphenix@unitycouncil.org Direct: 510-535-6943 Ashley Nelson, email: anelson@unitycouncil.org Direct: 510-535-7179

Come and be a part of what’s happening at OYE!

Oakland Youth Engaged

Application Oakland Youth Engaged Program (WRITE CLEARLY)

Signature: _________________________________________ Date:_________________

Applicant Information Name: Today’s Date:

Last First M.I.

Address: Street Address (Street Number & Street Name) Apartment/Unit # City ZIP Code

Cell Phone: ( ) Parent’s Cell #: ( ) Home Phone: ( )

E-mail Address: Birthdate: Age: Date turn 18:

Ethnicity/ Race:

Preferred language: Primary Language Spoken at Home:

What is your GPA?:_________

Are you a Resident of Oakland? YES NO

More information (please fill out to the best of your ability) NO

Gender Identity: ____________________________ Sexual Orientation:_____________________________ Circle all that apply:

Attending Alternative school ♦ Foster program ♦ Under Probation ♦ Working with a Case Manager Have been suspended/expelled from school ♦ Need US Citizenship services ♦ Failing one or more classes ___________

Identification (Bring a copy or original with you when submitting your application)

Do you have a current Photo ID? YES, PASSPORT YES, SCHOOL ID YES, CALIFORNIA ID Other: _____________________ NO

Education Grade:

Current High School (Name & Address): To:

From: To: Did you graduate? YES NO Degree: Year of Graduation:

Year:

College (Name & Address): To:

From: To: Degree: Year of Graduation:

Previous Employment –OR- Volunteer Experience Supervisor:

Company & Address:

Responsibilities:

Phone: ?

Job Title: End:

Start: End: Starting Salary: $ Ending Salary: $ Reason for leaving?

Do you have a resume? YES NO Are you eligible for employment? YES NO

Do you have work experience? YES NO

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

Date:

City of Oakland – Human Services Department

Oakland Fund for Children and Youth

RELEASE OF INFORMATION PROTOCOL Overview Oakland Fund for Children and Youth (OFCY) is required to conduct an annual independent evaluation to see if its programs are making a difference and how they can be improved. All programs funded by OFCY are required to have all clients sign a Release of Information Form stating that the client gives permission for the Grantee to input their information into a database (Cityspan) for purposes of evaluating program and fund performance. Every enrolled client (and their parent, guardian, or other legally authorized representative if a minor) must sign a Release of Information Form giving consent to being evaluated by the City and the designated evaluation consultant, including sharing information with and from Oakland Unified School District.

Administration Each OFCY-funded program is responsible for assigning an individual to administer evaluation consent at client intake. For youth under 18 years of age, the administrator will work with the client to secure parent or guardian consent for the minor to participate in evaluation activities, and to have their likeness photographed or videotaped.

The administrator will be responsible for communicating and explaining the following points orally to ensure that clients understanding how their personal information may be used. All parent and client Release of Information forms will be stored securely by the agency in the client document folder on site.

•By signing the Release of Information form, the client agrees to let Cityspan and the City’s contracted professional evaluation firm(s) access identifying client information. Client records from Oakland Unified School District may be reviewed.

•Data is stored in a password protected database (Cityspan) and anonymized before being analyzed. A client name or other identifying information will never be published in a report or other publicly available document.

OFCY-funded agencies can use the Release of Information – Evaluation and Photo/Video Permission Form provided by OFCY, or incorporate the form into existing client intake forms.

Documenting Client Consent for Release of Information The verification of client status completing the Release of Information form for each client is to be updated on the Cityspan information management system upon intake. All parent and client Release of Information forms will be stored securely by the agency in the client document folder on site.

Oakland Fund for Children and Youth Release of Information Administrative Protocol

City of Oakland – Human Services Department

Oakland Fund for Children and Youth Oakland Fund for Children and Youth Older Youth and Adult - Release of Information - Evaluation and Photo/Video Permission Form

RELEASE OF INFORMATION - EVALUATION AND PHOTO/VIDEO PERMISSION FORM The Oakland Fund for Children and Youth (OFCY) provides grants to many programs serving youth and their families in Oakland. OFCY programs serve thousands of youth ages 0 to 20 and their parents/ caregivers, and include everything from parent education programs to youth leadership and career development programs. As a participant in an OFCY-funded program, we are notifying you that all programs funded by OFCY are required to participate in an independent evaluation. Programs funded by OFCY are required to have all clients sign a Release of Information Form stating that the client gives permission for the Grantee to input their information into a database for purposes of evaluating program and fund performance. Every enrolled client must sign a Release of Information Form giving consent to being evaluated by the City and the designated evaluation consultant, including sharing information with and from Oakland Unified School District (if applicable). As part of the evaluation, you will to complete a survey. The survey questions ask what you do in the program, how much you like what you do, and demographic information. The survey will take about 15 minutes to complete. You will only have to answer the questions to which you feel comfortable responding. If you feel discomfort in answering any of the survey questions, you do not need to answer. During your participation in the OFCY-funded program, you may participate in an activity that is being photographed or videotaped; these photographs/video recordings may be used for promotional purposes.

RELEASE OF INFORMATION - EVALUATION OF PROGRAMS AND TRACKING OF PROGRESS

I give permission for the OFCY independent evaluators and program staff to review my school data (if

applicable), monitor my progress for the purpose of determining program effectiveness.

Your Name (please print): ____________________________________________________

Your Signature: ________________________________ Date ____________________

PHOTO/VIDEO RELEASE

I authorize OFCY or any third party it has approved to photograph or videotape me during the OFCY-funded

program activities and to edit or use any photographs or recordings at the sole discretion of OFCY. I understand that

I shall have no legal right or interest arising from the recording, including economic interest. I also agree to release

and hold harmless OFCY and any third party it has approved from and against all claims, demands, damages, and

liabilities arising out of or use of the recording.

Your Signature: ________________________________ Date ____________________

Oakland Fund for Children and Youth Older Youth and Adult - Release of Information - Evaluation and Photo/Video Permission Form

Tell us about yourself

Answer all questions completely. Please write clearly or type your answers and attach to the packet. 1. What makes you interested in ¡OYE! Oakland Youth Engaged? 2. Tell us about something you’ve done that you’re really proud of or a major challenge you had to

overcome. 3. Who is your current role model or someone that you look up and why? 4. When you think about your future, what careers interest you? 5. What do you feel are some of your strengths? 6. What do you feel are some areas that you would like to work on? (public speaking, etc…) 7. What do you enjoy doing in your free time (i.e. hobbies)?

Oakland Youth Engaged

OYE

Parent Consent & Media Release Form

Youth Name

Address

City Zip

I, , I give my child,

Permission to participate in the OYE Program. I understand the goal of the program and support services are to

assist my child in advancing in his/her education, learning about different careers, and gaining skills to secure and

retain a job. I further understand my child’s participant is conditional. If he/she is unable to abide by The Unity

Council guidelines, they may be dismissed from the program.

MEDIA RELEASE

I understand the importance of using images and/or video and sound recordings of program activities in printed

material, agency websites, videos, film and television broadcasts featuring the OYE Program. Therefore, I give

permission for The Unity Council and their program affiliates to use photographs and/or voice recordings of

my child during program activities. Photographs, video, audio recordings and the tapes, negatives, and digital

media from which images and sound recordings are made, shall be the property of The Unity Council, which shall

have the right to publish, reproduce, distribute and make other uses free of all claims on my part. It is my

understanding that my signature below releases The Unity Council from any financial or legal responsibility for the

use of media relations/promotional material(s).

Print Participant Name

Participant Signature Date

Print Parent/Guardian Name (If under 18)

Parent/Guardian Signature (If under 18) Date

Oakland Youth Engaged

OYE Medical Authorization Form

Youth Name: Age:

Address: Date of Birth:

City: Zip:

Do you have any Allergies? (Food/medicines) What are you allergic to?

Please list any medications or other important medical information here:

EMERGENCY MEDICAL SERVICES

I give permission to The Unity Council staff to seek emergency medical professionals to administer care including

the administration of CPR and or First Aid. I authorize The Unity Council staff to seek the required emergency

medical services necessary to maintain my child’s health status.

In the case of an emergency, please contact:

CONTACT 1

Full Name: Phone Number:

Relationship: Work Number:

CONTACT 2

Full Name: Phone Number:

Relationship: Work Number:

Participant Name:

Participant Signature: Date:

Print Parent/Guardian Name:

Parent/Guardian Signature: Date:

Oakland Youth Engaged

OYE

School Records Release Form

Date: ______________________________________________

School Name:

School Address:

School Administrative Staff:

As the parent/guardian of ________________________________ in grade _____, I grant permission for

student

_______________________________________ to forward his or her educational records, including

name of school

transcript, latest report card, health records, disciplinary reports and special education records and state

Student ID #, if applicable to:

The Unity Council

Attn: Oakland Youth Engaged

1900 Fruitvale Ave

Oakland, CA, 94601

Office: 5105356943

If a student is under the age of eighteen a parent or guardian must sign. If a student is over 18, he or she

may sign. In order to receive academic, special education, disciplinary reports, and medical records from

the school your child previously attended, we are required to obtain your written permission.

Print Parent/Guardian Name:

Parent/Guardian Signature: Date:

If participant is 18 or over:

Participant Name:

Participant Signature: Date: