 TO CONNECT YOUNG PEOPLE TO THE LAND AND TO THE FOOD
WE EAT
 TO PROVIDE MEANINGFUL WORK EXPERIENCE FOR COMMITTED
YOUTH
 TO CONNECT YOUNG PEOPLE TO COMMUNITY THROUGH
SERVICE
 TO DEVELOP A COMMUNITY OF YOUNG PEOPLE DEDICATED TO
CARING FOR THE EARTH AND GROWING HEALTHY FOOD FOR
OUR COMMUNITIES

TO APPLY FILL OUT AND RETURN
AFTER WE RECEIVE YOUR APPLICATION AND LETTER OF REFERENCE, WE WILL INTERVIEW ON THE
FARM SO THAT YOU MEET US AND WE MEET YOU.
FULL NAME: ______________________________________________
LAST FIRST MIDDLE INITIAL
HOME ADDRESS: ___________________________________________
CITY: ___________________________________________STATE: ______________ZIP: ____________
HOME PHONE: __________________ CELL: _______________
SEX: FEMALE___ MALE___ DATE OF BIRTH ____________________
MONTH/DATE/YEAR
PARENT/GUARDIAN NAME:___________________________________
PARENT/GUARDIAN WORK TELEPHONE:_________________________
THIS PERSON IS MY LEGAL GUARDIAN __ MOTHER __ FATHER__ RELATIVE:______________________
OTHER PARENT /GUARDIAN NAME:_____________________________
TELEPHONE :________________________
THIS PERSON IS MY LEGAL GUARDIAN __ MOTHER __ FATHER__ RELATIVE:______________________
CURRENT SCHOOL:__________________________________________
SCHOOL TELEPHONE:________________________________________
CURRENT GRADE LEVEL: ___________
NAME OF A TEACHER WHO KNOWS YOU WELL: ___________________
NAME OF A PERSON WHO WILL BE A REFERENCE: ________________
REFERENCE PERSON’S PHONE NUMBER: _________________________
THIS PERSON IS MY TEACHER___ COACH ___ EMPLOYER ___ OTHER___
GROW PITTSBURGH YOUTH PROGRAM
EMILY SCHEINES
ALLEGHENY COUNTY COOPERATIVE EXTENSION
400 NORTH LEXINGTON STREET
PITTSBURGH, PA 15208-2561
FOR MORE INFORMATION CONTACT EMILY SCHEINES, 412.473.2542