Work-Based Learning Student Interest Form

1

Today's Date* This field is required.

Date

2

Student Name* This field is required.

First Name

Middle Initial

Last Name

Suffix

3

Student's Date of Birth* This field is required.What is your birth date?

Date

4

Student ID NumberStudent ID or Lunch Number

6

Student Email* This field is required.Please share your email that will best to contact you.

example@example.com

7

Student's Phone Number* This field is required.Please share the best phone number to contact you.

Please enter a valid phone number.

8

High School* This field is required.What is your current high school?

Northwestern

Rock Hill

South Pointe

Virtual Academy

9

Were you referred to the Work-Based Learning Facilitator by a teacher or a school/career counselor?

YESNO

10

Name of Referring teacher or counselor.

First Name

Last Name

11

What is your career interest?* This field is required.Do you have an education pathway of interest? Do you have a career and technical pathway of interest?

12

What is your Career Major on your IGP?Specify which pathway you are interested in (e.g., health science, agriculture, automotive, culinary arts, etc.).

13

Specific Job or Industry of Interest?Identify any specific job roles or industries the student is particularly interested in.

15

Relevant Coursework: List any related courses that you have taken within the Career and Technical Education pathway (at ATC) or in the Traditional Education Pathway (at your home high school).

16

Prior Experience: Note any previous internships, job-shadowing experiences, or volunteer work in the field.

17

Certifications: Include any relevant certifications that you hold (e.g., CPR, OSHA, First Aid).

18

Transportation: How do you plan to get to the internship or job-shadowing location (e.g., personal vehicle, public transportation, parent drop-off).