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Worksite Agreement for YouthWORKS! 2016 Summer Jobs Program

  1. Please complete a separate agreement for each different position at the same worksite, if the supervisor, duties, and/or requirements are different.

  2. So that we may best meet your worksite needs and to make successful student referrals,will this worksite:

  3. Please list other youth employee restrictions for your worksite (for example, age):

  4. Please describe the skills your worksite would like interviewees to possess:

  5. Note: the youth must apply through our program's online application and meet our eligibility to participate in the program. He/she may visit for a link.

  6. Please complete information regarding the planned daily work schedule for this position, including a daily lunch break. Please remember that minors (age 14-17) may not work more than 5 hours without a lunch break of at least 30 minutes (per the Child Labor Law). Lunch breaks are unpaid.

  7. Youth do not ordinarily work evenings or weekends, but if this is desired for this position, please describe and we will review the request. Thank you.

  8. Please share any information or additional requests that you feel would help us in establishing a rewarding work experience for both you and the youth.

  9. Please read the following agreement and certification.

  10. Typing your name in the box above serves as the electronic signature of the representative of the Worksite authorized to enter into this agreement.

  11. Typing your name in the box above serves as the electronic signature of the direct supervisor of the youth assigned to this Worksite.

  12. Kelli Goetz

  13. 301.600.2221


  15. Leave This Blank:

  16. This field is not part of the form submission.