For what term are you applying for Work-Based Learning? *

Student First Name

Student Middle Name

Student Last Name

Graduation Year

Cell Number

Address

E-mail Address

Date of Birth

Homeroom Teacher

Do you have transportation daily without relying on others? *

Work Experience

What is your overall grade point average?

Are you on track for graduation?

Do you currently have a job? If yes, where and how long have you worked there?

Do you currently have a job? If yes, where and how long have you worked there?

Is this the job you plan on doing for your Work-Based Learning Internship?

Mother's Name

Mom's Place of Employment & Job Title

Mom's Cell Number

Mom's Work or Home Number

Father's Name

Father's Place of Employment & Job Title

Father's Cell Number

Father's Work or Home Number

What are your plans after high school?

What career related courses or program areas have you taken courses in at CHS?

What kind of career to you hope to have in the future?

Given the opportunity to work for any company in the community, what company would you choose? Why?

Attendance Record

Discipline Record

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?

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.