Work-Based Learning Student Application
Email address *
For what term are you applying for Work-Based Learning? *
Student First Name
Student Middle Name
Student Last Name
Graduation Year
Clear selection
Cell Number
Street Address, City, State Zip
E-mail Address
Date of Birth
Homeroom Teacher
Do you have transportation daily without relying on others? *
Work Experience
(Include previous employer, dates worked, and duties)
What is your overall grade point average?
(Use your best guess if you are unsure)
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?
Clear selection
Parent/Guardian Information
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
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)
Given the opportunity to work for any company in the community, what company would you choose? Why?
Self Evaluation
Attendance Record
Discipline Record
Social Skills (working with others)
Self Motivation
Enthusiasm (for assigned tasks)
Strives for Excellence
Mentally Alert (organization/problem solving skills)
Proper Etiquette or Manners
Personal Appearance/Grooming
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.
Please list the names of the two teachers you plan to ask to complete recommendations for you for WBL.
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