Cooperative Application Form

Co-op Application Form
Personal Information:
Full Name *

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State

Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
E-mail
Birth Date

Month Day Year
Place of Birth (City & State)
Color of Hair:
Color of Eyes:
Technical Program:
Certification Numbers:
O.S.H.A. 10 Hour (General Industry ) Required *
Additional Certification:

O.S.H.A. Construction ServSafe CNA Cosmetology
Certificate Number:
Student Employment Information
Do you have your own transportation to/from the job?

Yes No
Do you have a driver's license?

Yes No
License Number:
Please answer how you will get to/from work?
How far are you willing to commute to work sites? Some employers work several miles from the school and require students to be on the road early. Maximum:
Miles:
Minutes:
Are you available to work after school if requested?

Yes No
Are you available to work full time (40 hours) during your shop week?

Yes No
Please list any days and/or hours that you are unable or unwilling to work?
Do you agree to follow all the rules and regulations for participation in this program as outlined in the student handbook?

Yes No
Parent/Guardian Information
Parent Name

First Name Last Name
Parent Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Parent E-mail
Teacher References:
Teacher Reference *
Name of Reference
Class *
Teacher Email
Program Approval
Program Lead
Program Lead Email
Resume:

Formats pdf, doc, docx, txt, rtf.
Resume *
Send Application:
The statements and information furnished in this application are true and complete.

My signature certify that I have read and agree with the above statement.
Student Signature

Clear
Should be Empty:

Co-op Application Form

Personal Information:

Certification Numbers:

Student Employment Information

Parent/Guardian Information

Teacher References:

Program Approval

Resume:

Send Application: