Career Exploration Application

Career Exploration Requirements

Students:

Must be a senior
Must provide their own transportation
Must complete at least 120 hours at their chosen career placement
Must have and maintain good grades, attendance, and discipline at school
Turn in all required forms, time sheets, etc on time
Notify the course facilitator prior to resigning from the placement
Understand that quitting the placement will result in being dropped from the course which will negatively reflect on my transcript
Understand that being fired will result in being dropped from the course which again will negatively reflect on my transcript

Parents will:

Be supportive of and encouraging of a positive experience through this career placement
Communicate with the course facilitator if the internship interferes with the student's academic success
Notify the course facilitator if their student resigns from the internship position
Notify the course facilitator if there are any concerns

CSD will:

Designate a course facilitator to assist the student and employer and provide guidance
Provide Worker's Compensation Insurance

The Employer will:

Provide a safe working environment for all employees
Appoint a training supervisor for the student and facilitate training
If the placement is paid, pay the student at least the current minimum wage and conform with all local, state, and federal laws
Assess the student's progress via regular evaluations sent by the course facilitator and provide the student with a variety of experiences

Today's Date

Date

Name

First NameMiddle NameLast Name

Name that you go by:

Birthdate

Date

Which semester would you prefer your Career Exploratory class to be scheduled in?

Semester 1Semester 2

What block would you prefer your Career Exploratory class to be scheduled?

1st Block2nd Block3rd Block4th Block

Best Phone Number where student can be reached:

Parent/Guardian Name

Parent/Guardian Email Address

example@example.com

Parent/Guardian Cell Phone #

Where do you plan to complete your career exploration placement?

Place of Employment's Address

Place of Employment's Phone Number

Are you currently employed at this placement?

YesNo

If yes, how long have you been employed at this business?

Current career interest:

What are your plans after high school?

Is this placement related to your current career interest?

YesNo

If your Career Exploration placement is related to your current career interest, you qualify for a work based learning experience which will count as your Career Ready indicator.

Who will be your immediate supervisor?

What is the supervisor's title (Example: owner, manager, etc)

Supervisor's Email

example@example.com

Supervisor's Work Phone Number

Is this career placement paid or unpaid?

PaidUnpaid

Please list your duties

Please list any allergies or medical conditions that would be used in an emergency

I understand that I must work a minimum of 120 hours in order to receive credit for the course.*

Yes

I certify that the answers given are true and complete to the best of my ability and any false or misleading information given on this application or verbally to the course facilitator and/or my employer may result in the dismissal from the course. I also understand the requirements of enrolling in and successfully completing the Career Exploration course.*

My child has my permission to participate in CHS's Career Exploration Course. I understand that I will be responsible for arranging transportation to and from the work site. I also understand that school personnel will not be present on the site and thus, will not be responsible for my child. In the event of any injuries sustained by the student’s participation in this program, I will not hold Clover School District liable. I also consent for the course facilitator to contact my child concerning due dates for work hours, and any other school related matters via email, website and other professional methods of communication. I also consent for my child to receive emergency medical treatment in the event of an injury or illness.*

Career Exploration Application

Career Placement Information

Student

Parent/Guardian: