Summer Youth Work Experience Preference Form

Industries of Wayne and Holmes Counties, Inc.

Participant Name*

Check all that apply (you can do one, two or all three)

I want to participate in the weekly Zoom Training

I want to participate in Career Wednesdays

I want to have a job for the summer

1. I have the following work restrictions (please list any physical limitations such as, lifting and bending, or environmental limitations such as, allergies)

2.I cannot work on the following days and times. You must state a reason why you cannot perform work during those periods. Reasons could include lack of transportation, outside activities or family commitments - please be specific. Day and Time

Day and Time

Reason

3. Will you be taking any time off for vacations or summer camps? If so when will that be?

4. When will your last day of work be?

5. Transportation to work sites is not available. Please provide the maximum distance that you can travel from your home to a worksite.

How was this form completed with the client?

Case Manager Name

Goodwill