Work-Based Learning Student Application
*Required
When do you want to do Work Based Learning?
Which high school do you attend?
How many periods of Work-Based Learning would you like to take?
What part of the day would you like WBL scheduled? (Although we make an effort to meet your preference, your academic schedule must accommodate your request)
Student First Name
Your answer
Student Middle Name
Your answer
Student Last Name
Your answer
What is your student ID number?
Your answer
Date of Birth
MM
/
DD
/
YYYY
What grade will you be in when you want to do Work-Based Learning?
Address, City, State, Zip
Your answer
Mobile Phone Number
Your answer
Email Address
Your answer
Are you on track for graduation (passed all required graduation or end of course tests)?
What is your overall grade point average? (Use your best guess if you are unsure)
Who is your guidance counselor?
Your answer
Do you have transportation daily to and from work?
Do you have accident insurance?
(Insurance will be required to participate in Work-Based Learning)
What extracurricular activities do you participate in or outside of school?
Your answer
Work Experience (Include previous employer, dates worked, and duties)
Your answer
Do you currently have a job? If yes, where and how long have you worked there?
Your answer
If you currently have a job, what is your supervisor's name and phone number?
Your answer
Is this the job you plan on doing for your Work-Based Learning Internship?
How did you learn about the Work-Based Learning program? If a friend or a teacher referred you, please provide that person's name.
Your answer
Parent/Guardian Information
Mother's Name
Your answer
Mom's Place of Employment & Job Title
Your answer
Mom's Mobile Phone Number
Your answer
Mom's Work or Home Number
Your answer
Father's Name
Your answer
Father's Place of Employment & Job Title
Your answer
Father's Mobile Phone Number
Your answer
Father's Work or Home Number
Your answer
Career Information
What are your plans after high school?
What career related course, or program area have you taken courses in high school? (Courses other than required academics)
What kind of career do you hope to have in the future? (Provide as much information as possible)
Your answer
Given the opportunity to work for any company in the community, what company would you choose? Why?
Your answer
Self Evaluation
Attendance Record for (2014-2015)
Discipline Record (2014-2015)
Sense of Urgency
Select the word that best describes how regularly you practice this behavior
Appropriate Attitude
Select the word that best describes how regularly you practice this behavior
Problem Solving
Select the word that best describes how regularly you practice this behavior
Communication
Select the word that best describes how regularly you practice this behavior
Respect
Select the word that best describes how regularly you practice this behavior
Attendance
Select the word that best describes how regularly you practice this behavior
Initiative, Cooperation, Teamwork
Select the word that best describes how regularly you practice this behavior
Productivity
Select the word that best describes how regularly you practice this behavior
Appearance - Dress appropriately for the environment
Select the word that best describes how regularly you practice this behavior
Attention to Details
Select the word that best describes how regularly you practice this behavior
If a close friend or classmate was asked to describe you in 3 words, what would they say?
Your answer
You are required to provide two teacher references. Please provide their name and email address or phone number.
Your answer
Terms of Acceptance
I understand that enrollment in this program is limited and that making application for enrollment does not mean that I will be automatically accepted.
I understand that an interview with the coordinator will be required prior to a decision on my application.
I understand that once accepted, I must sign a WBL Agreement outlining my responsibilities and the program guidelines.
I understand that my grades, attendance, and behavior records will be checked by the coordinator prior to acceptance and must meet standards for me to be accepted.
I have parental/guardian approval to work during a portion of the school day.
I, the student, warrant the truthfulness of the information provided in this application. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Type Your Full Name
Your answer
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