Fall Creek Summer Work Registration
First Name
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Last Name
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Street Address
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City
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Zip Code
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Telephone
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Date of Birth
MM
/
DD
/
YYYY
Gender
Race
Parent First Name
Your answer
Parent Last Name
Your answer
Student has an Individualized Education Program
Student is at-risk by school District's definition
Expected H.S. Graduation Date
MM
/
DD
/
YYYY
GPA
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Current Grade in school
Program Type
Program Area (select one)
Starting Wage per hour
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Business Name
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Business Street Address
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Business located in what City
Your answer
Business Zip Code
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Mentor First Name
Your answer
Mentor Last Name
Your answer
Mentor Telephone
Your answer
Mentor Address
Your answer
Mentor Email
Your answer
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