Work- Based Learning Application
Student Information
What Gordon County High School do you attend?
When do you want to do Work-Based Learning?
Are you currently on track to graduate?
Have passed all necessary courses and/or assessments
Student First Name *
Your answer
Student Middle Name
Your answer
Student Last Name *
Your answer
Student Cell Number *
Your answer
Address *
Street, City, State, and zip
Your answer
Email Address
Your answer
Date of Birth
MM
/
DD
/
YYYY
Homeroom Teacher
Your answer
Do you have transportation daily without relying on others?
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, is this the job you plan on doing for your Work-Based Learning Internship?
If you do not have a job, what pathway area would you be interested in an internship?
Examples: Healthcare, Automotives, Construction, Agriculture, ECE, etc.
Your answer
Parent/Guardian Information
Parent/Guardian Name
Your answer
Parent/Guardian Phone Number
Your answer
Career Information
What are your plans after High School?
What Career Related program areas have you taken courses in during high school?
Courses other than required academic courses
Self Evaluation
Rate yourself from 1 to 5.
1 = N/A
2 = Unsatisfactory
3 = Needs Improvement
4 = Good
5 = Excellent
Good Attendance
Discipline
Social Skills (working with others)
Dependability
Self Motivation
Responsible
Punctual
Strives for Excellence
Organized
Proper Etiquette/Manners
Honesty/Integrity
Attitude towards Constructive Criticism
Ability to Learn Quickly and Adapt to Change
Communication Skills
Cell Phone/Social Media Control or Etiquette
You are required to have two teacher recommendation forms completed in order to participate in Work-Based Learning. Please provide the names of the two teachers you have provided instructions to for completing these forms.
Two Teachers Completing the Online Recommendation Form
Your answer
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