1. Read and complete all portions of the Request for Summer Youth (RFSY) pages. Please be thorough when listing job duties and responsibilities.

2. Due to limited number of youth to be served, we may not be able to accommodate all requests for youth to be placed at your site.

3. Please return to:
Davidene Alpart, Program Manager
Passaic County Workforce Development Center 200 Memorial Drive, Paterson, NJ 07505



This is a non-financial agreement between the PASSAIC COUNTY WORKFORCE DEVELOPMENT CENTER (PCWDC) and the AGENCY described below. This proposal is due by June 15, 2023.
Once approved, this agreement is valid from JULY 10, 2023 through AUGUST 25, 2023.

    NOTE: Indicate dates of operation that differ from dates listed above:


    Agency Name


    Phone Number

    Fax No.

    Contact Person


    2. ATTACH to this request incorporation papers and tax identification number verifying that your agency
    is either a public non-profit agency or a private non-profit agency. (Not applicable for municipalities,
    local education agencies or government agencies.)


    Complete the attached form for each job title requested. Use as many forms as necessary. List the
    address of the site where employment and training activities will take place. Attach additional sheets,
    if necessary (dates and places) if applicable to your agency. (Note: any activity, including field trips,
    that will take the participant off-site, must be listed. If dates/trips have yet to be arranged, that
    information must be forwarded to PCWDC at least 5 working days prior to the trip.)

    Will supervisor(s) be present at all times?

    Total number of youth requested in all job titles


    • All applicable federal, state and local laws, including Child Labor Laws, will be enforced. (Copy of Child Labor Laws will be furnished.)

    • Health and safety standards established under Federal and New Jersey law otherwise applicable to working conditions of employees is equally applicable to working conditions of participating youth.

    • It is understood and agreed that PCWDC staff shall have the right to periodically monitor and review all program activities and services provided by this Agreement to ensure compliance with the terms of the Workforce Innovation and Opportunity Investment Act (WIOA), its implementing regulations and the terms of the Agreement. Such monitoring, to be conducted through on-site visits and record review, shall include, without limitation, review of participant attendance and records; examination of work and program sites and work conditions, where applicable; and interviews of participants to determine job or program-related problems. Violations of this Agreement may result in forfeiture of participants and require reimbursement of their salaries to the PCWDC.

    • The AGENCY will only provide employment through the term of this Agreement to individuals approved and authorized as participants by PCWDC. Payments to non-approved individuals are the sole responsibility of the AGENCY and not PCWDC.

    • The AGENCY assures that the necessary work materials and/or equipment are available for training.

    • The AGENCY will adhere to PCWDC policies and procedures (attached) and any additional guidelines developed by the U.S. Department of Labor or Passaic County Workforce Development Center with regard to the operation of this program.

    • The AGENCY will maintain time and attendance records for participants as specified by the PCWDC. At the completion of the program, the AGENCY will submit progress reports on each work experience participant.

    • The AGENCY will immediately notify appropriate PCWDC staff in the event there is a work stoppage. No participant in work experience may remain working in any position, which is affected by labor disputes involving a work stoppage.

    • We further recognize and accept the fact that all funding is contingent on the availability of Federal funds and continued Federal authorization for program activities and is subject to amendment or termination due to lack of funds or authorization.

    • The AGENCY will update the information contained in this agreement as required.

    • The AGENCY will comply with Title VI and VII of Civil Rights Act of 1964, as amended and Executive Order 11246 - Equal Employment Opportunity. The AGENCY assures it will not discriminate with respect to any PCWDC participant because of race, creed, color, national origin, sex, age, political affiliation, belief or handicap. The AGENCY will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: a) the Age Discrimination in Employment Act (ADEA); b) the Americans With Disabilities Act (ADA) ; c) the Equal Pay Act; d) the Immigration Reform and Control Act of 1986(IRCA); e) Title IX of the Education Amendments of 1972; and the requirements of any other non-discrimination statute as applicable.

    • The AGENCY will not utilize open-back vehicles to transport PCWDC participants to or between sites. Failure to comply with this regulation will result in the AGENCY assuming total responsibility for any and all injuries, results of such injuries incurred while using this form of transportation.

    • The AGENCY assumes all liability for the participants for job related actions taken during those hours indicated as in attendance at their site. A Certificate of Liability Insurance must accompany this Agreement and must list the “Private Industry Council of Passaic County, Inc. dba Passaic County Workforce Development Center” in the certificate holder box. General liability coverage limits shall not be less than amounts reflected on the attached Sample Certificate of Insurance. While the PCWDC has assumed the cost of Workers Compensation Insurance for participants, the AGENCY is not absolved of its duties as stated in this agreement.

    • It is agreed that for paid summer youth employment experiences, individuals will be compensated in accordance with applicable State or local minimum wage law or the Fair Labor Standards Act of 1938.

    • The AGENCY will assure that a summer employee will not displace (including a partial displacement, such as a reduction in the hours of non-overtime work, wages, or employment benefits) any currently employed employee.

    • The AGENCY will assure that a youth will not be employed in a job if any other individual is on layoff from the same or any substantially equivalent job.

    • The AGENCY will assure that a youth shall not be employed in a job if the employer has terminated the employment of any regularly employee or reduced the workforce of the employer with the intention of filling the vacancy so created with the participating youth.

    • The AGENCY will assure that the job is created in a promotional line that will not infringe in any way upon the promotional opportunities of currently employed individuals.

    • The AGENCY will assure that the employment of a youth will not impair an existing contract for services of collective bargaining agreement. In addition, the written concurrence of the labor organization and the employer is needed for youth employment activities that are inconsistent with the terms of the collective bargaining agreement.

    • The AGENCY will assure that the youth cannot carry out the construction, operation or maintenance of any part of any facility used or to be used for religious instruction or as a place for religious worship.

    • The AGENCY will assure that no youth may be placed at a worksite if a member of that youth’s immediate family is directly supervised by or directly supervises that individual.

    • The AGENCY will assure that no youth will be placed at a casino or other gaming establishment, aquarium, zoo, golf course or swimming pool


    I, the undersigned, am authorized to certify that all information contained in this request is accurate to the best of my knowledge. This AGENCY further agrees to abide by all of the information in this request for participants.








    PCWDC is an Equal Opportunity Employer. Auxiliary aids and services are available upon request to individuals with special needs.

    Worksite Application Instructions

    Please read all instructions before completing the form to make sure that appropriate information is included. Your attention to detail will help us properly place youth at your site, so please complete all questions on the form.

    Please complete a separate form for every job title

    • Make sure the correct worksite location is listed. If your agency has more than one site, please fill out a form for each site. We need to know exactly where the youth will be working.

    • List the correct contact person at each site with their phone number, etc. Our youth and staff need to know who they should report to and where they are reporting.

    • Indicate the exact hours of participation. If there are different time frames for the same job, clearly indicate the exact times youth will be working.

    • Item #7: Occupational Skills and Responsibilities: these are the job-specific tasks a youth will be performing. Make sure to be as detailed as possible so the youth and staff will understand the assignments and responsibilities that will be expected. This helps us to match the youth with a specific summer job.

    • Item #8: General Work Principles: these personal behaviors are commonly known as employability skills or soft skills and should include the requirements and attitudes needed to work on the job.

    Should any information change after the application is submitted, please notify us and update the form as necessary. Your cooperation is appreciated as we make placements for the 2023 Summer Youth Work Experience Program.



    Failure to do so may eliminate job site from consideration

    Agency Name

    Site Address:

    Site Contact:

    Site Phone:


    1. Job Title

    2. Number of Participants

    3. Dates of Operation: from To Daily Hours: from To

    Note: Youth under 18 years of age must receive a 30-minute meal period after 5 consecutive hours of work.

    4. Supervisor/Trainer (Name)

    5. Job Title of Supervisor/Trainer

    6. Ratio Supervisor/Trainer to PCWDC Participants

    7. Occupational Skills and Responsibilities

    List a minimum of five (5) job skills specific to this job that a participant will learn. (e.g.; for a clerical position: answering phones, faxing, filing, photocopying, typing, etc.)

    Job Skills/Responsibilities

    Specific Method
    (Hands on, observation, etc.)

    Type of Supervision
    (Manager, Peer, etc.)






    8. General Work Principles (e.g. workplace behavior, appropriate attire) that a participant will learn.





    9. Position Qualifications (age, skills, special requirements).





    10. Inclement weather provisions: Describe Not Applicable Note: Outdoor sites lacking an inclement weather policy will be reviewed accordingly



    Sites utilized must conform to information requested on worksite agreements, and all worksites must be indicated on the agreement.

    The PCWDC must be informed prior to any site changes. We reserve the right to approve/disapprove such requests.

    The number of participants must conform to the numbers agreed upon by the PCWDC and the worksite on the Request for Participants.

    All machinery and equipment utilized must conform to job description, worksite agreement, and Child Labor Laws.

    The worksite agreement must indicate the agency/organization’s status. Participants may not engage in political or religious activities.

    The worksite agreement must clearly indicate the duties and responsibilities of participants during the summer.

    If the site is outdoors, the PCWDC must be informed of the agency/organization’s policy for participants during the inclement weather.

    • Outline of availability of meaningful work indoors;

    • If youth are sent home due to inclement weather, they will only be paid for hours worked.

    The worksite’s contact person and title as well as supervisor(s) shall be indicated on the worksite agreement.

    Work must take place between Monday and Friday unless other arrangements have been made and approved by PCWDC.


    The site supervisor or a designated alternate as named in the worksite agreement, must be present during work hours of all participants assigned to such worksite.

    The site supervisor or a designated alternate must possess the necessary abilities and skills to direct and coordinate participants’ work assignments.

    All jobs must provide legitimate work experience. This should include, but not be limited to, occupational skills, job responsibilities, appropriate work behavior, planning, working with others, following instructions, communicating and problem solving.

    Adequate supervision must be provided to participants during their regular working hours. This includes any travel between sites, field trips, etc. If participants will be traveling, the PCWDC Counselor/Monitor must be informed.

    The site supervisor must establish a system for participants to contact the site supervisor, within 15 minutes of their start time, if they cannot report to work.

    Supervisor to participant ratio must conform to the worksite agreement. The maximum allowable supervisor to participant ratio is 1:12. PCWDC reserves the right to modify the ratio as deemed appropriate. Reasons may include, but are not limited to: type of work, type of site.


    No youth will be paid by PCWDC unless they have been certified by PCWDC and referred by PCWDC, have working papers and have a PCWDC start date.

    Youth will be paid by PCWDC only for time designated by PCWDC. Participants will be paid only for hours they have worked as indicated on the time sheet.

    Participants’ work hours and all signatures must be indicated on time sheets in ink.

    No participant may work more than the number of hours per week determined by PCWDC. Participants will not be paid for any hours exceeding this limit.

    All participants who work a minimum of 5 hours per day must have a minimum one-half hour lunch break per day. Lunch is not to be considered as paid time. It must be indicated on the time sheet

    Participants are to have comparable working conditions.

    Participants are not to replace laid-off workers.

    Participants may not, under any circumstances, cash their paychecks during the hours for which they are being paid to work.


    Time sheets are considered legal documents. They may not be filled out in advance.

    Time sheets should only record actual hours worked for PCWDC. Any additional hours agreed upon between youth and AGENCY will not appear on PCWDC time sheet

    Time sheets must be maintained and checked by the supervisor.

    Should it be discovered that any participant receives payment for time not worked, the result can be the loss of all participants assigned to that site and PCWDC must be reimbursed for those payments.

    Do not use white-out on the time sheets. (Cross out if necessary).


    Written warnings will be utilized in conjunction with counseling techniques to develop proper work habits.

    The following situations may result in termination of a participant.

    • Excessive absences: 2 or more in a pay period

    • Excessive lateness: 2 or more in a pay period

    • Not calling in when absent or late: 3 times during the work experience program

    • Not following the rules of the job site.

    • Inability to meet the standards of the job site as defined in the worksite agreement. (Not able to do the assigned work, inappropriate dress, etc.)

    The PCWDC Counselor/Monitor should be informed of any participant who is in jeopardy of being terminated. Terminations will only be implemented by PCWDC.



    Please describe all current COVID-19 PROTOCOLS and POLICIES for the worksite. We understand that rules are subject to change and would appreciate updates as they occur.

    Source of worksite polices, e.g. State, County, Local, Internal rules

    Specific policies regarding:

    • Social Distancing

    • Masks

    • Vaccinations

    • Mandatory weekly testing

    • Other requirements

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