Work-Based Learning Student Application
For what term are you applying for Work-Based Learning? *
Student First Name
Your answer
Student Middle Name
Your answer
Student Last Name
Your answer
Graduation Year
Cell Number
Your answer
Address
Street Address, City, State Zip
Your answer
E-mail Address
Your answer
Date of Birth
MM
/
DD
/
YYYY
Homeroom Teacher
Your answer
Do you have transportation daily without relying on others? *
Required
Work Experience
(Include previous employer, dates worked, and duties)
Your answer
What is your overall grade point average?
(Use your best guess if you are unsure)
Are you on track for graduation (passed all required graduation or end of course tests)?
Do you currently have a job? If yes, where and how long have you worked there?
Your answer
Do you currently have a job? If yes, where and how long have you worked there?
Your answer
Is this the job you plan on doing for your Work-Based Learning Internship?
Parent/Guardian Information
Mother's Name
Your answer
Mom's Place of Employment & Job Title
Your answer
Mom's Cell 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 Cell Number
Your answer
Father's Work or Home Number
Your answer
Career Information
What are your plans after high school?
What career related courses or program areas have you taken courses in at CHS?
(Courses other then required academics)
What kind of career to 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 (2016-2017)
Discipline Record (2016-2017)
Discipline Record (2016-2017)
Social Skills (working with others)
Dependability
Self Motivation
Responsibility
Enthusiasm (for assigned tasks)
Strives for Excellence
Punctuality
Mentally Alert (organization/problem solving skills)
Proper Etiquette or Manners
Personal Appearance/Grooming
Integrity/Honesty
Iniative/Drive
Atitude Toward Constructive Criticism
Ability to Adapt to Change
Teamwork/Cooperation with Other
Communication Skills
Attention to Detail
Sets Realistic Goals
Cell Phone/Social Media Control or Etiquette
If a close friend or classmate was asked to describe you in 3 words, what would they say?
Your answer
You are required to have two teacher recommendation forms completed in order to participate in Work-Based Learning. You should have received the instructions to provide to the teachers to complete the erecommendations.
Please list the names of the two teachers you plan to ask to complete recommendations for you for WBL.
Your answer
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