Please return to Mrs. Voyles in room E-203 What Periods are you requesting 1 2 5 6 7 8

Douglas County School System

Work-Based Learning Application

Student: Name ______Grade ______Advisor______

Address: ______

Home Phone Number ______Cell Phone Number ______

E-Mail Address: ______

Parents/Guardians: Mother ______Work Phone Number ______

Father ______Work Phone Number ______

Mother’s E-Mail Address ______

Father’s E-Mail Address ______

Employment: Are you presently employed: ______yes ______no if yes, please complete the following section:

Name of Employer (Business Name) ______Phone Number ______

Address ______

Supervisor ______your rate of pay ______

Please list your previous work experience (starting with the most recent and working backward)

Job Title / Employer (Company) / Dates / Reason for Leaving

If you are accepted into the work-based learning program, will you have transportation to work? ______

Education: Write your current class schedule below:

Class Period / Subject / Teacher
1
2
3
4
5
6
7
8

What is your overall grade point average: 4.0 to 3.0 ____ 2 .99 to 2.00 ____ 1.99 to 1.0 _____

List three teachers who are familiar with your scholastic and work performance that you would ask to recommend you for the work-based learning program:

(1) ______(2) ______(3) ______

Number of days absent from school last year: ______

if more than 6, explain why______

Special Interests:

What CTAE Pathway are you currently taking courses?______

What courses have you completed in this pathway? ______

Why do you want to participate in the work-based learning program?

______

What kind of career do you envision for yourself in the future?

______

What are your post-secondary plans?

______

Are you a member of a CTAE student organization? _____ if yes, please check all that apply.

____DECA ____FBLA ____HOSA ____Skills USA ____GCSA ____FCCLA ____Other (list)______

List any special skills that you can bring to a company that chooses to hire you as a result of participation in this program. In addition, describe the benefits that you expect to gain for yourself, if selected.

______Checklist of items to submit:

_____ Application

_____ Copy of Transcript (I will request this for you)

_____ Copy of Discipline Record (I will request this for you)

_____ Copy of Driver’s License

I certify that I have completed the above application form after careful consideration. If I am accepted for this work-based learning program, I will take advantage of every opportunity to improve my skills and efficiency in the classroom and the world of work. I agree to abide by all rules, regulations and guidelines of the work-based learning program.

If accepted into the WBL program, I understand that I must report to the WBL Coordinator during the first three days of the semester for WBL orientation.

Student Signature ______Date ______

Parent/Guardian Signature ______Date ______

The Douglas County Board of Education does not discriminate on the basis of sex, race, religion, national origin, disability, or age in the educational programs, activities, or employment practices.