WBL I Application
Student participation in WBL is contingent upon the submission and approval of application by the district's CTAE Coordinator.

(updated 2.20.2020)
First Name *
Your answer
Last Name *
Your answer
School email account (00000@coastalplainscharter.org) *
Your answer
Date of Application *
MM
/
DD
/
YYYY
Application Site *
STUDENT CONTACT: Cell phone number (use 000-000-0000 format -- or enter 229-000-0000 if there is NO cell phone) *
Your answer
Number of WBL Segments Requested *
Birthday *
MM
/
DD
/
YYYY
Emergency Contact Name *
Your answer
EMERGENCY CONTACT: phone number (use 000-000-0000 format -- or enter 229-000-0000 if there is NO cell phone) *
Your answer
Place of Work
Your answer
WORK PHONE: Offical phone number for the worksite (use 000-000-0000 format -- or enter 229-000-0000 if there is NO cell phone) *
Your answer
Work Address (123 Main Street, City, ST ZIP)
Your answer
Supervisor's Name *
Your answer
SUPERVISOR'S CONTACT NUMBER: (use 000-000-0000 format -- or enter 229-000-0000 if there is NO cell phone) *
Your answer
Start Date (Choose the first day of the month that you started) *
MM
/
DD
/
YYYY
Job Title *
Your answer
What career do you wish to pursue after graduation? *
Your answer
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