Work-Based Learning Application

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Student Information needed for placement: Application plus EDP, Resume & Transcripts to be returned to Ms. Harwell, Career Services Coordinator.

Email *

What is your First Name? *

What is your Last Name? *

What is your address? *

Street Address of where you are living.

What city do you live in? *

City.

What is your zip code? *

What High School do you attend? *

Big Rapids HS

Big Rapids Virtual HS

Chippewa Hills HS

Crossroads Charter Academy

Evart HS

Morley Stanwood HS

MOSAIC

Reed City HS

What is your Date of Birth *

Month Day Year

What is your home phone number or personal cell phone number? *

What is your email address?

What MOCC Program are you in? *

What session do you attend MOCC? *

What is your Career Goal after High School? *

What is the full name of your parent or guardian? *

First Name & Last Name

What is your parent's emergency contact number for you? *

Do you live with this parent or guardian? *

Yes

Full name of an emergency contact if we cannot reach your parent? *

First & Last Name, Relationship to contact.

Please list other phone numbers that would be helpful in reaching you?

Parent not listed previously, cell number, home or work numbers.

What is the name of the employer that you plan do do your work-based learning with? *

What is the employer's contact information? *

Phone, address, etc....

Have you talked to this employer about your desire to do work-based learning? *

Yes

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