Columbia City High School

Columbia City High School

Interdisciplinary Cooperative Education

Student Application(Must be a Senior)

Whitley County Consolidated Schools Corporation is committed to equal opportunity and does not discriminate on the basis of age, race, color, creed, sex, handicapping conditions, or national origin including limited English proficiency, in any employment opportunity. No person is excluded from participation in, denied the benefits of, or otherwise subjected to unlawful discrimination on such basis under any educational program or student activity.

Name______

LastFirstMiddle Initial

Social Security No______-_____-______Age______Birthdate______

Home Address______

StreetCityZip

Home Phone # ______-______Cell Phone # ______- ______

Name of Father/Guardian ______

Name of Mother/Guardian ______

Number of times I have been absent from school this year? ______

Number of times I have been tardy from school this year? ______

School subject I like the most______Least ______

Extracurricular activities you plan to participate in your senior year?

______

Why do you wish to enroll in the I.C.E. Program?

______

______

List three faculty references that can recommend you. Current Class Schedule

1. ______1st per. ______

2. ______2nd per.______

3. ______3rd per.______

What is your long term occupational goal?4th per. ______

______5th per. ______

______

______

What is your career interest?______

Are you planning to enter the workforce after graduation or are you planning to

_____1. attend a 4 year college_____2. attend a business college

_____3. attend a technical college_____4. enter the workforce

List the trade or occupation for which you would like to receive further training through the ICE Program:

1. ______2. ______

(1st choice)(2nd choice)

Are you currently employed? ______Yes______No

Where are you employed: ______

Do you want to use this employment for your ICE Placement? _____ Yes ______No

What trimester will you be interested in? (Check all that apply) 1____ 2____ 3____

List one former employer:

1. Name of company:______Phone:______

Address:______Supervisor:______

List all the courses you have had to prepare you for your occupational goal:

Subject:Grade Earned:

1. ______

2. ______

3. ______

4. ______

Add any other information that you would like to share that you think would be useful in the decision-making process of acceptance for the ICE program.

______

I understand that I must provide my own transportation to and from the training station before I can be considered for the ICE Program.

______Drive my own car______Parents will provide my transporation

I promise that, If I qualify for the ICE program, I shall accept whatever responsibilities are placed before me in the class, on the job, and program activities (employer-employee appreciation banquet, fund-raising activities). I further agree that the information provided by me on this application may be used by the teacher-coordinator while seeking my employment for the purpose of vocational training.

Student’s Signature______

I shall do my part in assisting my son-daughter to fulfill all obligations to the ICE Program including regularity in attendance and maintaining a satisfactory scholastic standing.

Parent/Guardian Signature______

COLUMBIA CITY HIGH SCHOOL

INTERDISCIPLINARY COOPERATIVE EDUCATION

PERMISSION TO RELEASE SCHOOL RECORDS

The ICE Coordinator of Columbia City High School has my consent to release a copy of my school records to prospective training sponsors and/or employers. The following information may be released.

Transcript of GradesVerification of Birth Date

Attendance RecordGrade Point Average

Health RecordsExtra Curricular Data

School ReferencesICE Application

Disciplinary RecordOther:

______

Signature of Student Signature of Parent/Guardian

______

DateSignature of ICE Coordinator