Example of Certificate of Employment in Department Store - DOC - DOC

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Example of Certificate of Employment in Department Store - DOC - DOC Powered By Docstoc
					                Chambers County Board of Education
                      Program for Exceptional Children and Youth
                                  Diane Sherriff, Coordinator
                             P. O. Box 408-D  LaFayette, AL 36862
                             Telephone 334-864-9466  706-586-1985
                      LIFE SKILLS COOPERATIVE EDUCATION
                     STUDENT APPLICATION FOR ENROLLMENT

Name________________________________Social Security No._____________________

Address______________________________Telephone No._________________________

Age___________Date of Birth_________________(Birth Certificate Required for Work Permit)

Do you have a driver’s license? ( ) Yes ( ) No       Do you have access to a car? ( ) Yes ( ) No

Occupational Program Completed or Enrolled in __________________________________

Career Objective____________________________________________________________

Parent/Guardian Name(s)_____________________________________________________

Parent/Guardian Address_____________________________________________________

Parent/Guardian Business Telephone____________________________________________

Are you interested in summer employment? ( ) Yes ( ) No ( ) Full-time ( ) Part-time
*Note: It will not count toward Cooperative Education requirements.

Indicate the type of business in which you prefer to work: (Example: bank, dental, department
store, legal, manufacturing, insurance, medical, etc.)

First Choice___________________________ Second Choice__________________________

Reason for above preference____________________________________________________

What courses (other than career/technical) have you taken relating to your career objective?
________________________ __________________________ _______________________

________________________ __________________________ _______________________

Do you intend to further your formal education after high school? ( ) Yes   ( ) No

Are you under a doctor’s care? ( ) Yes ( ) No Do you have any health problems which would
interfere with your regular attendance on a job? ( ) Yes ( ) No If so, please explain
____________________________________________________________________________
                                          Previous Work Experience
                                         (List most recent position first)
           Employer                           Type of Work                   Employment Dates




                                             Current Class Schedule
    Block                     Class                         Teacher              Grade Point Average
      1st
      2nd
      3rd
      4th
List as references the names of three (3) teachers who can attest to the quality of your work.

    1.   ____________________________________________(Career Tech Ed. teacher)
    2.   ____________________________________________(Case manager or transition aide)
    3.   ____________________________________________ (One Other teacher)




To the Student:

Life Skills Cooperative Education provides an opportunity to be considered for employment in
businesses and industries in our area. When you enroll in Life Skills Cooperative Education, you
indicate that you are sincerely interested in putting forth your best efforts to receive on-the-job
training. If you accept this responsibility, please sign in the space provided.

Student Signature_________________________________________ Date_________________

To the Parent/Guardian:

Do you consent to your child entering Life Skills Cooperative Education and agree to cooperate
with the school and the training agency in making the training and education the greatest
possible benefit to your child? If so, please indicate your support and approval with your
signature.

Parent/Guardian Signature_____________________________________ Date__________




                                                                                                       2
To Be Completed By Case Manager/Transition Aide
**Attendance Record: 10th grade No. Absences/180 days_________________=____%
                                       No. Tardies_______________________
                     11th grade No. Absences/180 days_________________=____%
                                       No. Tardies_______________________
                       th
                     12 grade No. Absences/____ days_________________=____%
                                       No. Tardies_______________________

*Current Disciplinary Record: Total Reports________________
                       11th grade No. of Class II offenses___ No. of Class III offenses____
                       12th grade No. of Class II offenses___ No. of Class III offenses____
Cumulative GPA:___________________

**List Career Technical courses taken:
______________________________________________
_______________________________________________
_______________________________________________
**Alabama Graduation Exam Attempted ( ) Yes ( ) No
**Portions of the Alabama Graduation Exam Passed _____________________________
**Results of evaluations completed employers for community-based work experiences or
previous employment
(Site/Results)___________________________________________________________________
(Site/Results)___________________________________________________________________
Status of Application:             ( ) Pending       ( ) Approved         ( ) Not Approved
Comments:____________________________________________________________________
Date Employed______________________________
Employer___________________________________
Employer’s Address_____________________________________________________________
Supervisor/Mentor______________________________________________________________
Telephone_______________________________ Beginning Rate of Pay $__________________
*Verified by Administrator_______________**Verified by Counselor_____________________




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