1. Are you the parent or legal guardian?
*
Yes
No
2. What is your First and Last Name?
*
First Name
Last Name
3. What is your child's first and last name?
*
First Name
Last Name
4. What is your phone number?
*
-
Area Code
Phone Number
5. What is your email address?
*
example@example.com
6. How old is your child?
*
7. What school does your child attend?
*
8. Please select the option that best applies to your child.
*
My child has a 504 plan
My child has an IEP
My child has another document which verifies that they have a disability
9. Youth must complete the entire program for our organization to remain in compliance with State requirements. The student must complete 10 sessions.
*
My child will be able to complete the entire program
My child will not be able to complete the entire program
10. Does your child have any allergies? If so please indicate below
*
11. What industry is your child interested in?
*
Arts and Recreation
Educational Services
Financial Services
Healthcare/Medical
Hospitality/Tourism
Information Technology
Manufacturing
Marketing/Public Relations
Media/Entertainment
Real Estate/Property
Retail
12. Does your child have any medical issues that staff should be aware of? Such as a seizure disorder or asthma? If so, please describe below:
*
13. Do you provide consent for Career Focus, Inc., to use images and/or video footage of your child for marketing and promotion purposes such as Flyers, Brochures or social media ?
*
Yes
No
How did you here about our program?
*
Submit
Should be Empty: