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