Work-Based Learning Student Application 2017-2018
This is the application for students interested in participating in the Work-Based Learning program. Please complete this application. You will be contacted by Dr. Folds to set up an interview and parent meeting.

Griffin Spalding School System does not discriminate on the basis of race, color, religion, sex, national origin, age or disability in its programs or employment practices. GSCS employees and contractors must adhere to this policy at all times.

Date *
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Student Information
Student First Name *
Your answer
Student Last Name *
Your answer
Student Street Address *
Your answer
Student City *
Student State *
Student Zip Code *
Birthdate *
MM
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DD
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YYYY
Cell Phone #
Your answer
Student E-mail Address *
Your answer
Grade Level *
School *
What career/job do you want after high school and/or college? *
Your answer
Check any Career Tech/Fine Arts/World Language courses you have completed. *
Required
Why are you interested in the Work-Based Learning Program? *
Your answer
List your school/community activities, honors received, or offices held. *
Your answer
Student Employment Information
Where are you currently working? (You must have a job to be enrolled in this program). If you do not currently have a job, type that in the box. *
Your answer
Your current supervisor's name. *
Your answer
Your employer's address. *
Your answer
Hourly Wage *
Your answer
Hours you work during the school week (Monday-Friday) *
Your answer
List your PREVIOUS work experience. (Include employer, job title, dates of employment, and reason for leaving) *
Your answer
Do you have consistent, daily transportation to work? *
What obligations do you have that will interfere with your ability to commit time after normal school hours to this program? *
How do you believe participating in the WBL program will help you? *
Your answer
What is your GPA? *
Are you on track for graduation? *
Parent/Guardian Information
This section is contact information for the parent/guardian you live with.
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent Street Address *
Your answer
Parent City *
Parent State *
Parent Zip Code *
Teacher Recommendations - Please list the names of three teachers who will provide a recommendation for you to participate in the WBL program. *
Your answer
Certification
I certify that the facts contained in this application are true and complete to the best of my knowledge, and understand that – if selected for Work-Based Learning, falsified statements may be grounds for removal. I authorize investigation of all statements contained herein, the references provided with this application, all information concerning previous employers, and release all parties from liability for any damage that may result in furnishing the same to you.

I understand to be in the WBL program, I must work at least 10 hours during the school week. I also realize all communication will be through my GSCS.ORG email.

As Parent/Guardian of the below named student, or the below named individual who is 18 years old, I hereby authorize Griffin-Spalding County Schools Work-Based Learning to release only school related information and records for the following individual as it pertains to Work-Based Learning and the participating school. It is understood that the party to whom this information is released will not release it to a third party. I understand and agree to the above statements.

A hard copy of this certification statement will need to be signed by the student and parent/guardian in a meeting with Dr. Lea Folds.

Griffin-Spalding County School System does not discriminate on the basis of race, color, religion, sex, national origin, age, or disability in its programs or employment practices. GSCS employees and contractors must adhere to this policy at all times.

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