JK Movement Youth Application (Ramsey County)

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Through federal state-funded grants, Ramsey Country and the JK Movement can offer opportunities to eligible youth.

If you are eligible for the JK Movement program, you will work with a counselor to identify specific goals and opportunities available to you.

Please answer all questions to the best of your ability. A JK Movement staff will be available to assist. If you are under the age of 18, a parent/guardian signature is required.

Please bring a copy of the following documents to your meeting:

A copy of your Social Security Card or a W2
A document which verifies your date of birth (Birth Certificate, Driver’s License, or other state ID)
If you are not a US citizen, provide verification of immigration status (Lawful Permanent Resident care or other INS documentation)

If you are missing documents, the staff will work with you to get them.

Please read the Minnesota Data Practices Act.

Minnesota Data Practices Act

Your Right to Privacy

As an applicant for or participant of the JK Movement program, you will be asked to provide information that is classified as private data. Under the Minnesota Government Data Practices Act, you have the right to know what use will be made of the private information you provide.

Authority to Collect Data

The JK Movement operates programs in Ramsey County to help eligible youth to be quality people and active citizens in their community and workplace. As part of its responsibilities, the JK Movement is authorized to ask applicants and participants for information that is necessary to determine their qualifications to participate in the program.

Purposes and Uses of Data Collected

The information asked for will be used by the program’s staff to determine your eligibility for participation. The information will be entered into a record-keeping system and staff whose jobs reasonably require it will have access to the information to provide the best possible training and service to you. Other government agencies, including the Minnesota Departments of Employment & Economic Development, Human Rights and Human Services, the United States Departments of Health and Human Services, Labor, Housing and Urban Development and Agriculture, and the Legislative Audit Office may examine the information for program monitoring, evaluation, or audit purposes.

Data may be given to other service providers to coordinate the service for you or to determine your eligibility or suitability for services from other programs. It may also be given to local and state welfare agencies for monitoring your eligibility for any assistance programs, or for any employment or training program administered by those agencies. Any other uses of the information provided will be for statistical or research purposes only and will not disclose any personally identifying information about you.

Effects of Non-Disclosure

You may be asked to provide data that you are not required to give to qualify for services. Failure to complete these items will adversely affect your eligibility. However, you are encouraged to complete all the items to allow for a more complete assessment by staff. Intentional misrepresentation of information (lying) may result in termination from enrollment in any services with the JK Movement.

I have read the above Data Practices information. I have had the opportunity to ask any question about this material and how it applies to my situation.

Participant Name *

This will also act as a signature for acknowledging the above information

Parent/Guardian Name (Participant Name if 18+) *

This will also act as a signature for acknowledging the above information

Date *

YYYY

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