Coastal Harmony Job Shadow Application

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Name: *

Email: *

Street Address, City, State, Zip Code: *

Cell Phone Number (for personnel file only): *

Date of Birth: *

YYYY

Current school you are attending: *

Will you need a school excuse form? *

Yes

Emergency Contact: *

Emergency Contact's Relationship to Student: *

Emergency Contact Phone Number: *

REFERENCES

Please give the names and contact information of two people you are not related to and have known you for at least one year.

Reference #1: (Name, Email, & Phone Number) *

Reference #2: (Name, Email, & Phone Number) *

AVALIBILITY

What days and times are you avaliable? *

BACKGROUND

What are your hoping to gain from this job shadow experience? *

APPLICANT'S AGREEMENTS & ACKNOWLEDGEMENTS

By time stamping, I acknowledge that all the information herein are true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this application void. *

YYYY

Time

By time stamping, I authorize Coastal Harmony to conduct any investigation it deems appropriate concerning my application. I hereby authorize and request personal references and government agencies to disclose criminal record, work ethic, and any other information that may be sought in connection with this application. I hereby release all of the above mentioned from all liability in connection with those disclosures. *

YYYY

Time

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