CA Job Placement Form
Thank you for taking the time to fill out this Placement form. By filling this out, you will be entered into an end of the school year raffle! Any questions, please reach out to your job coach!
Name
*
First Name
Last Name
Email
*
example@example.com
School Name
*
Please Select
Cambridge Extension
Chelsea High School
Everett High School
Malden High School
Revere High School
Somerville High School
Woburn High School
Gender
*
Please Select
Male
Female
Transgender
Nonbinary
Prefer not to answer
Date of Birth
*
-
Month
-
Day
Year
Date
Please select how you identify
*
American Indian / Alaska Native
Asian
Black / African American
Cape Verdean
Hispanic
Multi-Race
Native Hawaiian / Other Pacific Islander
White
Other
Grade
*
Please Select
9th Grade
10th Grade
11th Grade
12th Grade
Graduation Year
*
Employer/Placement Name (I.E. Target, MGH, Market Basket etc.)
*
Employer/Placement Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title (i.e. Camp counselor, retail associate, intern, etc.)
*
Start Date
*
-
Month
-
Day
Year
Date
Hourly Pay (Enter Numbers only - i.e. $14.50)
*
Hours per Week (Enter Number only - i.e. such as '15')
*
What type of placement did you get?
*
Employment
Paid Internship
Unpaid Internship
Volunteer Opportunity
Is there anything you would like to share with us about your job/internship place experience?
Submit
Should be Empty: