PICKENS COUNTY COLLEGE AND CAREER CENTER COOP APPLICATION 2021-2022

PICKENS COUNTY APPLICATION FOR COOP ENROLLMENT
Today's Date

MonthDayYear
Date
First Name
Middle Name
Last Name
Maiden Name
Street Address
City, State, and ZIP Code
Telephone Number
Cell Phone Number
Email Address
example@example.com
Age
Date of Birth

MonthDayYear
Date
Do you have a driver's license?

YesNo
Do you have access to a car/other mode of transportation?

YesNo
Career Objective:
1st Choice
2nd Choice
3rd Choice
Parent/Guardian's Name
Parent/Guardian's Email Address
example@example.com
Parent/Guardian's Cell Phone Number
Street Address
City, State, and ZIP Code
Indicate the type of business in which you prefer to work: (Example: bank, dental, retail store, legal, manufacturing, insurance, automotive, medical, etc.)
First Choice
Second Choice
Do you intend to further your formal education after high school?

Technical training2 year4 yearMilitaryWork full-time
Are you under a doctor's care?

YesNo
Do you have any health problems that would interfere with your regular attendance on a job?

YesNo
If yes, please explain...
Current or Previous Work Experience

(List most recent position first. If this is your first job type NA)
Employer #1
Type of Work
Employment Dates
Employer #2
Type of work
Employment Dates
Employer #3
Type of Work
Employment Dates
Current Class Schedule
1st Period Class
1st Period Teacher
2nd Period Class
2nd Period Teacher
3rd Period Class
3rd Period Teacher
4th Period Class
4th Period Teacher
5th Period Class
5th Period Teacher
6th Period Class
6th Period Teacher
7th Period Class
7th Period Teacher
List as references the names of three teachers who can attest to the quality of your work. One must be your current or previous occupational teacher.
Reference #1 (Career and Technical Education Teacher)
Reference #2
Reference #3
To the Student:

Work-Based Learning provides an opportunity to be considered for employment/training in business and industries in our area. When you enroll in Work-Based Learning, you indicate that you are sincerely interested in putting forth your best efforts to receive work-based experience. If you accept this responsibility, please sign in the space provided.
To the Parent/Guardian:

Do you consent to your child entering Work-Based Learning, providing transportation, and agree to cooperate with the school and the training agency in making the training and education of the greatest possible benefit to your child? If so, please indicate your support and approval with your signature.
Student's Signature

Clear
Today's Date

MonthDayYear
Date
Parent/Guardian's Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

PICKENS COUNTY APPLICATION FOR COOP ENROLLMENT

Current or Previous Work Experience

Current Class Schedule