Emery’s Young Entrepreneurs
1100 47
th
Street, Emeryville, CA 94608
A Career Internship Program for Emeryville’s Youth
510.601.4907
PROGRAM & JOB APPLICATION
Applicant’s Last Name
First Name
MI
Gender
Birth Date
Social Security Number
Age – Youth 14-24 are eligible
Cell Phone Number
Home Phone Number
Alternate Phone Number
Home Address - Youth must live in Emeryville
City and Zip Code
What is your ethnicity? Please check all that apply.
€ African American (non Latino Black)
€ Latino
€ Arabic
€ Asian/Pacific Islander
€ White (non Latino White)
€ Asian Indian
€ Other - Please specify
Citizenship and Employment Eligibility – Please check all that apply.
€ US Citizen € Alien Registration €Student Visa € Amnesty Program € Other
If you were not born in the United States, what is your country of birth?
Parent/Guardian Name
Phone Number
Alternate Contact Name (Relative or Friend)
Phone Number
SCHOOL & JOB TRAINING QUESTIONNAIRE
Are you a student?
€ Yes € No
If Yes, where?
Are you attending school this summer?
€ Yes
€ No € Not sure
If Yes, where?
Have you graduated from High school?
€ Yes € No
If No, still in school? € Yes
€ No
What school will you attend next school year?
What grade are you in right now? € 7
th
€ 8
th
€ 9
th
€ 10
th
€ 11
th
€ 12
th
€ GED € HS Equivalency € College
Have you ever participated in another job training program? € Yes € No
In what areas are you interested in working or receiving training? Please check ALL that apply.
€ Office Administration
€ Computer Technology
€ Recreation/Childcare
€ Retail Sales
€ Health