Paid Work-Based Learning

Paid Work-Based Learning
Are you the parent or legal guardian?*

YesNo
What is your First and Last Name?*

First NameLast Name
What is your child's first and last name?*

First NameLast Name
What is your phone number?*

Area CodePhone Number
What is your email address?*
example@example.com
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How old is your child?*
What school does your child attend?*
Please select the option that best applies to your child.*

My child has a 504 planMy child has an IEPMy child has another document which verifies that they have a disability
Youth must complete the entire program for our organization to remain in compliance with State requirements.*

My child will be able to complete the entire programMy child will not be able to complete the entire program
Does your child have any allergies? If so please indicate below*
What industry is your child interested in?*

Arts and RecreationEducational ServicesFinancial ServicesHealthcare/MedicalHospitality/TourismInformation TechnologyManufacturingMarketing/Public RelationsMedia/EntertainmentReal Estate/PropertyRetailConstructionAgriculture
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: *
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 ?*

YesNo
How did you hear about our program?*
Should be Empty: