A. School System: Blithe County B. System Number: 010101 .

C. School: Blithe County High School D. School Number: 020202 .

E.  School Street Address: 100 High School Road .

City: Small City TN Zip Code: 37000 .

F. School Phone: (423) 555-1111 G. School Fax: (423) 555-2222 .

H. Activity: (check one)

¨  Apprenticeship (Registered) / ¨  Health Science Clinical / ¨  Service Learning Method
þ  Transition / ¨  Cooperative Education / ¨  Success Skills Through Service Learning Class
[If you check this box, complete I-M, omit N-R and skip to S.]
¨  Student Learner Program
Apprenticeship or industry credential: ______

I. Related Course (specific title): IEP Transition Plan J. Course Code: 9498 .

K. Teacher Name: Jill Jones L. Teacher License #: 00004607082 .

M. Coordinator’s Name (if not teacher of related course): same .

We do hereby certify that training agreements are on file at the employer/training agency and school for each work-based learning student listed below. In addition, we certify that each student listed is employed or placed during school hours for a portion of his/her daily work period. (Files are subject to audit).

Teacher Signature (related course) Jill Jones Date September 24, 2000

WBL Coordinator Signature (if not related course teacher) same Date ______

Director of Schools Signature Dennis Johnson Date ______

N.
Name of Student / O.
Employer / P.
Type of Business/Classification / Q.
Job Title
(must relate to course) / R.
Hourly Wage
(if applicable)
EXAMPLES
John Doe / Dillard's / Department Store / Salesperson / $ 5.25
John Doe / Daily News / Newspaper / Copy Assistant / $ 6.00
Billy Ray Jones
Kenny Landrum / K-Mart Garden Center
All Creatures Animal Clinic / Department Store/Garden Center
Vet Office / Garden Shop Clerk
Vet. Assistant/Tech. / $5.55
$7.00

*Please use an asterisk to identify names of students who have changed jobs this school year

**Penalties may be imposed for systems not in compliance with state and federal WBL guidelines.

N.
Name of Student / O.
Employer / P.
Type of Business/Classification / Q.
Job Title
(must relate to course) / R.
Hourly Wage
(if applicable)
Patti Smith
Hannah Washburn
Jacob Yoder
Jackie Young
Mark Zukowski / Big Lots
Friendly Vet.
Food Lion
Greene Recycling
Ford Motor Co. / Department Store
Veterinary Hospital
Grocery Store
Recycling Center
Car Dealership / Store clerk
Vet. Assist./Tech.
Stocker
Machine Operator
Detailing Cars / Training
Training
Training
Training
Training

*Please use an asterisk to identify names of students who have changed jobs this school year

**Penalties may be imposed for systems not in compliance with state and federal WBL guidelines.

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