United StatesDepartmentof the Interior
FISH AND WILDLIFE SERVICE
HumboldtBayNationalWildlife RefugeComplex
P.O.Box 576, 1020RanchRoad
Loleta,Califomia 95551
(707\733-5406Phone
(707\733-1946
Fax
www.firs.gov/refuges/humboldtbay
Aprtl21,2014
Dear InterestedStudent:
Attachedyou will find an applicationandmedicalform (4 pages)for participationin the Youth Conservation
Corps(YCC) programsponsoredby the U.S. Fish and Wildlife Service.This is an 8 weekprogramopento
malesand femalesbetweenthe agesof 15-18.The programstartsJune23,2014 andendsAugust 15,2014.
Students'19thbirthdaymust not fall within programdates.Studentswill be paid at a rateof$8.00/hr. Thejob
is 40 hoursper week,Monday - Friday.The workday startspromptly at 8am. This programinvolvesoutdoor
work in the form of habitatrestorationand enhancement,
maintenance,
and includesan environmental
educationcomponentaswell. One crew will be assignedto the SalmonCreekUnit of HumboldtBay NWR
Complexlocatedin Loleta,and a secondcrew will be assignedto the LanphereDunesUnit in the Arcata
Bottoms. Thereare 5 positionsavailablein eachcrew. Studentsmust provide their own transportation to
and from the duty station of their assignedcrew. Participants must commit to working the full 8 week
term.
IIow to Apply:
1. Fill out the applicationand medicalform. Studentsunderthe ageof 18 musthavea parent'ssignature.
2. Obtaina Work Permitfrom school
3. Selectionis random,neithercoverlettersnor resumesarerequired.But, eitherwill be acceptedif attached.
4. Formscanbe returnedvia Mail/FAX or In Personto:
Ken Griggs
HumboldtBay National Wildlife Refuge
P.O.Box 576, 1020RanchRoad
Loleta,CA 95551
Fax: 707-733-1946
5. Formsmustbe receivedby closeofbusinesshoursFriday,May 30,2014.
Ifselectedyou and your parent(s)/guardian
will be requiredto attenda two hour eveningorientationduringthe
week of Junel6th. Dateand time to be determined.At which time you will fill out additionalpaperwork,get a
briefoverview ofthe refuge,and an outlineofjob responsibilities.
If you haveany questions,pleasefeel free to email or call me at [email protected]
or (707) 733-5406.
We hopeyou chooseto apply and becomepart ofa wonderfulwork experience.
Sincerely,
Ken Griggs
DeputyRefugeManager
Humboldt Bay National Wildlife Refuge
W€RlHK
Corps
UnitedStatesYouthConserYation
The Pfogram
The Youri ConservaronCorpstYCC]rs a i{eJl-balancedwork-learn-earnprogtamtha'
?aveiops an uoderstafiding
and appreciationin panieiFali.gyourhot iie Nation's
environmenrand her:tage.11isadministeredby lhe U.S.Depaimentof AgricultureForestService,and by the U.S.Depanmentoi the Interior-Fisil and WildlifeService
and NationalParkService.YCC oifersgainluisummerempioymentto youth,for
approxjmately
elgirtweeks,in a heallhluloutdooralmosphere.
Enrolleeswrl[be paic the minirnumwagefor a 40 hour work we€k Most projectswiil
enroll.anequalnumberof rnalesand iemalss.
Proieclsinclud€buiidingtrails,maintainingiences,cletnangop campgrounds,
improvingwiJdliiehabiia! and thinningtimbersiancs-Participantswil| do hard physical
work and nraybe expasedto insects,poisoaoak and ivy,adv€rselyeath€aand diificllt
vrorkrngconditions.
Blgibiuty Requirsfi erts
Youngmenand women,15 througir18 yea,sot age,who are permaned resrdentsoJ
are eligibl€to. empioymentwithoul
tho UnitedSlates,ils Terdtories,or possessions,
regardto social,eccnomie,racial,or elhnicbackgrounds.Handicappedyouth wllo can
ettectiveiytarticipate in rftostYCC aclivities are eligible,Youlh must have no hisrory of
seriouscriminalor othsrantisocialbahaviorthat mighlendangertheit saietyor that ot
others: lrave or be able to cblsin a work permit as required und€t fie laws ot thetr Statq
havea SociaiSe6uri{yfturnberor have{nad€applicaliontor oneibe willing and able to
wo.k hard and panicipansin most work projed.s.Employmentis without regard to Civil
S€ryice of classitlsagoniaws, .ui€, or regulalions,
llow Vou Can €nroll
Io appiy,yolth meerngihesequaliticationsthouid compietetiis YCC applicationform
afld .eturnil ai the earljestpossibledateto the nearestunrtol a NationalPatlENaional
Forest,or NationalFisnand WildlifeRefugeor Hatchery.
Aoolica s wiil be seiectedon a €ndom basisand wi,l be notiliedol selectian.
Demographicinfoimationsucn as age.race,and farnilyincomeis not used in the
s€lectionorocess.
Public re0onrnq b!rce, ior rf1r3cotlecaion01 inlormatton rs es$malsd to ave.aqe 3 mrnule3 per resgons€.
including :hE lrlne lor levrew'Bg rnsrudtons. soarcbing exEtrng dala sources. garherhg and marnlatnrng lhe
da& nee€ed, and compt€nnc ard revre\ring ihe colleclion olinlormaiot. S€nd comrnents iegatding t|tis bu,den
estmare or 3nv olier asoecr of {l!!s coll€aron ol !nlo.matron, rnc,udrng sug99360ns ,or reouctng 1nrsburd€n, to
OepEn|fi€nr ot Agrrc\rlllre. Cieerance Offlcer, OIBM. noom 4o4-w, Wain|nglon. o.C,20250: and to lha Oftio€ oi
,lsnagamenr and Budget Pape.*o.x Eeduclion Protect (OMg tO5g5-O084),Washidglofl. C,c. 20503,
YCC 0onll€s w(h SeEron :04 01thp Rehrotlikror Acl of 1973. 129U.S. CodB i941, Undsr fii3 ,tcl add
,an9lemenlnq f,egulatlons- nancllcapgoo oatsonS "!,/no, wrlh l6asonebl9 accofirnodalon, aan lgrlorm lne
esssnllal tundrons oi the YCC a.s etqrblG. i7 SFI Parl15b and 4t CFR Pad 17)
cMB No.9596-0084
Youth ConservationCorps (YCC) Applicaiion
YCC Exh'bit1.1
Ptint or Typeatl answers.All ques*onsand stEtemenismus!be answ€reoic enaote
seleclicn olfice ro cieiermine
appricant'seligibiiiv and avariabjjitv.
rncamoarc aaptrcatnas
may naveta be rcjacted.Authoriv is PL g3-4o9.Duringthe termoi emptoymenl.
you musi
be al least ]5 yearsol ageand not have reachedage j9.
Name{Last-First-Middle
tnitiat}
Social SecurityNumber
[I-m n-rn
M3le
Date oi Birth
m-m rl-rn
Semale
Monih Oay
Year
MaitjngAddress{Streelor P.O.Boxl
City
State
Area Code
ZipCooe
Telephone Number
Area Code
rTTr-Trn
n-rn
TelephoneNumber
[I-[n-rT] n
Home
ln €ase ol €mer,gency
Appllcan!'s Statemert
YCC i€ an Eqlai
Opponuntty Employer
I am familiarwidrths YCC programand jnlorestedin workingir' th€ outdoorsto dovelopand
maintain th€ naurar rssourcss of rh€ unirad slates, rt sEi€cled, I vil obtain s work psrrnil
it
r€qu,l€d. I haye or am appiyinglor a social s.clrily nurnbsr. I am a psrmafisnl r.sid€nt ot
the Unitsd States of hs Tsrriloriasor posssssions. I do not have a history oi sgrious ariminal
or othe.,artisociai bahavio.'thatrnightjeopardizo, y satetyor lhat ot orhers. rcsnilythat arl
intormalionI havs giv€n aboyeis tru€ and corsct to tha best ot my knowl€dgo.I harr6not
partisipatsdin any YCC program,or more thang ry€eksin the past, norhave
l submfied
duplicatedapplications.lncorrsc'tstatgrn€ntscoostiturggroundslo. imm€{iid€dismissai.
You hav€ my permissionto givs this arplicationto any yCC of,iciallor whosscamo I am
selsaled.
{Signarureol AppJtcan!)
1l;ountyJ
I am tamiiiarwrtn lhe yCC program and the applrcant ias rny permtssion lo
oan|crpate,
rsrgnatuaeol Parent or 6uaroian)
?.grous edthor rs oosolete.
iDare)
-ov:F-
FS-180O'r8(1C/94)
part ll - Io be cornpletedby parent qr guardian
of lhg applicant
lhis is ia ceni! ihat ; am iafiii;ar wiii the Youth Conservatisncorps Prcg€m and that I give .nv coisent io my
somdaughterlvrard
io Parlicipaiewalhihe progremas a YCC me.nber. I understancjthat fwiil rot hotdthe Unit;d States
Covernment;esgonsiblelor aay non-programac.identcr illnessancjI authorizeilrst aid or emergencym€dicatcare10be
qe:-formed
at ihe iearest.nosl adeqsatefacilityapprovedby the yCC.
1. €mergencyconaad lNameand Relat-tonshig
I
i
1
2.
d Address(Streel,C;ty,StateandZp Code)
o. ulg.larureltsarentcr t;uardlan)
6. Date
rcenslyrn €marKsblosk,any .ondilon ihat v{ouldre$riclfull partjcipalionanddescribearryspecialcare-i trEat6EitiEEi__
maybe required-
1. Heavy tifting, 45 pguqds and rler
2. tleavy carrying 45 polnds and ove.
3, Straight plllliog
!. Puillngiand orc. hand
5. Pushi.g
6- Reachingaboveshoulde.
7- Use cffmge|s
Basic tunctional .equiromentg for orltdooi v,otk
8, Bottr hands requircd
15. Climbing,use ol legsand arms
9. Watking
16. ao(h legs Equi.ed
10.9hndlng
17, Far vision csre<*ablg in one eye
i'1. C.ararling
io 20/20 and to 20140in the othet
12. Kneeilng
18-Hearing(aid pemitted)
i3. Repeatedbendl.g
14.Climbiog,
legsonly
Environmd.lEl tactors
1, Outside
2. Excessiveaeat
3, Excessse cold
4. Elc€ssive hr.rmidilv
5, Excessivedampnessor chillirg
6- Dry ahospneric condiliots
7. Excessive n6ise, intefmittenl
8. Ousr
g. StiFperyor urevea lElking gqrlaces
10 Working arounc .novi.tg obteds or
11.Wo.kingon larjdersor icaffotdiog
12,Workrngwith hendsin $rat€r
13. Wo*inE dos€hywith othe(s
14.Wo*ing alone
REMARKS{Enter inloffiatjon regading any prescibed medication, rcacfiansto penicitlin ar any d gs and1orafty olher
haalth pmbtems of whi6h we shaald be made autare.l
Ptblic fepoEingburdenfor this cojlectjonaf inlo,matioais eslimaledto arrerags3 rtiouieBpor €sponse, including
the time fof rev|ewrng
rn$ftlctaons.
s€archiagexislingdata so!tces. gathednqand msrntaini.grhed;Ia reeded. aod comgletingano reiiewing
the co ectignof
infoFnation.Sendcommeots.€gg.dingltris buder estimat€or any oihleraspett ol this collectionof inloination.
inctudingsuggesroosicr
tec'leng lSis burden.11]Deps(fienl ctAgnc!l!!,e. cjeaGnce offlcer.ctRM: Room404-w- \4la"rrington,
oi, iifZ.:fi; inj t'o-r'he
oncs ot
ldanagemenrand Bldget paperlyorkRsduqior pro'ecl iCIAB;0596-0084],Washindo., D_C.20503. . FS Revtewtng oificers sEnature
g. Dars
'U.S^ePO:1991-813-671/40475
ClrB No.C:ge-Cc8d
Exhibii i_2
Youth ConservationCorps
MedicalHisto
'ileriar,e.erlheen,olee"or*i-c!,0g,".-"-='^i:i{ti?l{l"'i;i"J.]f
iffiTffi*:""';f"',1"":"j"."*.m*lt;l$
reauesled
.r a v.tuntartbasis:;:cwevef.
iailure
ic ccrntlgieN.tis
lom..4ff,iirifin ax"*",on,roritlheor.drsm
-
Yes
_
ta\ct
tlsea,se5,,/
_
No
jtyes, listnameoiinsur€r
in block4,
.<u /ou nave Daa any
Rhesmati6 _
Tuberelosis _
Diabet€s
Ft€quent Infestions
Other health conditioh3
Colds
Sore throat
bar adte
Bladderor
inteslinal
iniectior
Hetnia
Poor hearing
Difficuitywiih
-senseof balanc€
Hoorvrsron
Problen wilh
bloodnot cloltjng
Def€ctsin iegs
oareel
Convulsions
Fainting
Sleepwalkiro
fleadactre
Stutieing
Nervsusccndiiion
b.Areyouallergicjoanymedicattons?
_
yeS
_
Diabetic
pregnancy
Swotienoi
painfuljoints
Shortnessof
breath
Chestpains
Easyiatigue
Heartcondilion
Emolional
problem
Back toubie or
injury
Persislentcough
Rheumatismor
arthritis
Loss ofryeight
Lyme disease
O\het iidenw)
No _ ifyes,explainonback.
unlessyau have rcceivedoneoi.a boojter.:wftninha last-lei yia;)
Dale oi
orisinar
series
_
Diphlheia
: o my knowledge.I have nor beenexposed--idEi6iEii6iEo-of reatthlvhrchwouldatlowfutiparticrpatton
,n u,fvCCictii i".
Prevrousediiionsof lhis torrn a.e cbsolete
,"T:'"gi*m:f;