APPLICANT INFORMATION – ALL INFORMATION MUST BE CLEARLY PRINTED. Full Legal Name: Date of birth Mo/Day/Yr: Age: SSN: Ethnicity: Street Address: Gender: Male Female Prefer not to say City: State: ZIP Code: Email: Home Phone: Cell Phone: Are you a citizen of the United States? YES NO If no, are you legally authorized to work in the U.S.? YES NO SCHOOL INFORMATION School (Tacoma Public School Required): Address: Expected Graduation Date (Mo, Yr): *June, 2015 Graduates are not eligible. Current Grade level: Do you have a documented disability/IEP? YES Phone: If yes, will you need accommodations on the work site? YES NO Please explain: _________________________________________________________ NO GPA: Are you currently credit deficient? YES History of disciplinary actions: Have you ever reported to Truancy Court? YES NO NO Are you currently or have you ever been in Foster Care? YES NO AVAILABILITY nd SJ253 mandatory 20-hour orientation week: June 22 , 2015 – June 26th, 2015 SJ253 work calendar: July 1st, 2015 – August 14th, 2015 Please list the hours of your availability: Sunday Monday Tuesday Wednesday Thursday Friday Saturday From To Comments concerning availability: _________________________________________________________________________________________________ Do you have summer vacation plans? YES Do you plan to attend summer school? Are you presently employed? YES YES NO NO NO If yes, when?: _________________________________________________________ If yes, where? ________________________________________________________ CERTIFICATIONS (EXAMPLES: WA FOOD HANDLER CARD, CPR, ETC.) 1. 2. Do you have a valid WA Driver’s License? YES NO Will you need assistance with transportation to work? YES Do you live near a bus line? YES NO NO SKILLS INVENTORY – PLEASE CHECK SKILLS RELATED TO YOUR ABILITY Working Outdoors Food Service Providing Customer Service Basic Typing and/or Data Entry Fire/Emergency Training Operating Phone Systems Working with Children Gardening/Landscaping Working in an Office Setting Managing Inventory Microsoft Office (Word, Excel) Creating Arts and Crafts EMPLOYMENT HISTORY Employer: From (Mo/Yr): To (Mo/Yr): Position: Employer’s Phone: / / Employer’s Address: Description of Job Duties: Reason for Leaving: EMERGENCY CONTACT Name of Emergency Contact: Emergency Contact’s Address: Relationship to you: Emergency Contact’s Phone: TEACHER REFERENCES (AT LEAST TWO) – REQUIRED Teacher’s Printed Name Teacher’s Email Address: Teacher’s Signature: 1. 2. ESSAY ESSAY PROMPT: Why is participating in the Summer Jobs 253 internship program important to you? Instructions: As you respond to the essay prompt, think about who will read your statement and what you want them to understand about you. While your personal statement is only one of many factors we consider when making our acceptance decision, it helps provide context for the rest of your application. Essays must be typed, double spaced, and a minimum of 650 words. Please attach your completed essay to the Summer Jobs 253 student application. PARENT/GUARDIAN SIGNATURES I certify that the information provided is accurate and complete to the best of my knowledge. I understand that any falsification may cancel any terms, conditions or privileges of employment. I understand submitting a completed application does not guarantee placement in the Summer Jobs 253 program and late applications will not be considered. Signature of applicant: Date: Signature of parent/guardian: Date: Application Deadline: Tuesday, March 31st, 2015 Please return the completed Summer Jobs 253 application to your career counselor. Late applications will not be considered.
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