Summer Pursuit Lab 2020 Pre-Registration Form

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Workplace Readiness & Work-Based Learning Session: July 20th - August 13th, Monday-Thursday 9am-12pm

Email *

First Name (offical/legal) *

Last Name (offical/legal) *

Date of Birth (of student) *

YYYY

The student named above meets the following requirements for the provision of pre-employment transition services: 1. Is between 16 years of age and 21 years of age; 2. Is attending a secondary, alternative, GED prep, post-secondary or vocational education program; and 3. Is receiving special education services, or is an individual with a disability for purposes of 504 eligibility. *

Yes

Phone Number (may add home, cell, and alternative) *

Emergency Contact Name & Phone Number (may add home, cell, and alternative) *

MAILING ADDRESS (INCLUDE CITY, STATE, AND ZIP CODE) *

STUDENT ID NUMBER (High school name) if no longer in a high school, say which high school and when you graduated. *

GENDER *

Female

Male

Prefer not to say

Submit

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