Student Registration Form
Fill out the form carefully for registration
Student Full Name
*
First Name
Middle Name
Last Name
*
Example: 1234
Student Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Student Phone Number
*
Student E-mail
*
example@example.com
Please verify your email
Student Gender
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you over 18 years old?
*
No
Yes
What School do you attend?
What grade are you in?
*
Ninth Grade
Tenth Grade
Eleventh Grade
Twelve Grade
I graduated form school
I attend college
I dropped out of school
Other
Have you been employed before?
*
Yes
No
This will be my first job
Do you have a resume?
*
No
Yes
I need your help to create a resume
Other
Will you have reliable transportation to and from work, if hired?
*
No
Yes
I will catch the bus
I will catch an Uber/Lyft
My guardian will take me to and from work
Other
Select the time frame that you prefer to work, if hired? (select all that apply)
*
Morning
Afternoon
Evening
Night
Overnight
Other
Do you have to report to any of the following?
*
Probation Officer
Case Manager
Mentor
Judge
No, I do not have to report to anyone
Other
Do you have a felon?
No
Yes
If you said yes to having a felon, please explain below
Note: some jobs prefer not to hire based on background, but this does not automatically disqualify you.
Do you have a misdemeanor?
No
Yes
If you said yes to having a misdemeanor, please explain below
Note: some jobs prefer not to hire based on background, but this does not automatically disqualify you.
Emergency Contact Information Section
Parent or Legal Guardian Full Name
*
First Name
Last Name
Parent or Legal Guardian Phone Number
*
Please enter a valid phone number.
Parent or Legal Guardian Alternate Number
Parent or Legal Guardian Email
example@example.com
Additional Comments
Please list anything that you would like us to know in this box. Ex. Skills, Training, Job Preference, Availability
Please sign in this box before submitting your application
*
Please verify that you are human
*
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