Clove School District 2017-2018 Work–Based Learning Application

Date: ______________________________

Personal Data

Full Name: _____________________________________________________________ Name you go by: __________________________________

Birthdate: ______________________________________________ Grade Level: ________________________________________

Cell Phone #: ___________________________________________ Home Phone #: _____________________________________

Address: _______________________________________________ City: _________________________ State: _____________ Zip: ___________

Parent/Guardian Information

Parent/Guardian Name: ___________________________________________Email Address: _____________________________________________

Parent/Guardian Daytime Phone#: __________________________________Parent/Guardian Cell Phone #: _______________________________

Parent/Guardian Work Phone #: ____________________________________

Emergency Contact other than parent: ______________________________ Emergency Contact Phone #: ________________________________

Career Information

Current Career Interest: _________________________________________________________________________________________________________

Plans after High School: _________________________________________________________________________________________________________

Employment Information

Place of Employment: ____________________________________________________________________________________________________________

Employment Address: ______________________________________________________________Phone #: _____________________________________

Name of Immediate Supervisor: ____________________________________________________________________________________________________

How long have you been employed with this company? ____________________________

List your duties:

Student Medical Information

List any medical information about the student that would be helpful in an emergency:

List any allergies to medications:

List any allergies or medical conditions that would be needed in an emergency:

Parent/Guardian Permission

Parent/Guardian:

My child,__________________, has my permission to participate in the CHS Work-Based Learning Program. I understand that I will be responsible for arranging transportation to and from the work site. I also understand that school personnel will not be present on the site and thus, will not be responsible for my child. In the event of any injuries sustained by the student’s participation in this program, I will not hold Clover School District liable. I also consent for the WBL Coordinator to contact my child concerning due dates for work hours, required paperwork, and any other school related matters via email, website and other professional methods of communication.

Parent/Guardian Signature: ___________________________________________________________________________ Date: ___________________________________

I consent for my child to receive emergency medical treatment in case of injury or illness.

Parent/Guardian Signature: ___________________________________________________________________________ Date: ___________________________________

Student:

I certify that the answers given are true and complete to the best of my ability and any false or misleading information given on this application or verbally to the WBL Coordinator and my employer may result in the dismissal from the WBL program with a failing grade and I will receive no credit. I also understand the requirements for entering the Work-Based Learning Program and for maintaining my eligibility throughout the year.

Student Signature: ___________________________________________________________________________________ Date: __________________________________