Fulton County School System Work-Based Learning Application. Placement Criteria Check List
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1 Fulton County School System Work-Based Learning Application Placement Criteria Check List Student s Name School Career Pathway Area Item 1 Application Distributed Returned Follow-up Request 2 Parent Information 3 Parent/Guardian Consent Form 4 Teacher Recommendation 5 Teacher Recommendation 6 Teacher Recommendation 7 Counselor Sign-off Sheet 8 Unofficial Transcripts 9 Student Attendance 10 Discipline Record 11 Training Agreement 12 Safety Agreement 13 Training Plan 14 Employer Information 15 Work Permit* 16 Copy of W-4 Form *Required for students under 18
2 Fulton County School System Work-Based Learning Application (Please print or type all information and return the completed packet to by ) Name (Last) (First) (Middle) Which Career Pathway are you currently enrolled and would like to apply for a Work-Based Learning Experience Grade Level Have you applied to or participated in another work-based learning program? If so, please list. of Birth Soc. Sec. No. Home Phone if available Address (Street, House/Apt.) (City, State, Zip) High School Counselor Father/Guardian Work Phone/ Occupation Employer Mother/Guardian Work Phone/ Occupation Employer Name of parent(s) with whom you reside: List the courses you have taken or are scheduled to take that apply to your work-based learning program: Are you employed now? YES NO Current Employer s Position List other employers and jobs you have had in the past: PREVIOUS EMPLOYERS DATES POSITION
3 Work-Based Learning Application Student s Name List current extracurricular activities: Do you have any personal or family obligations, which would prevent you from meeting a job commitment? Please circle one: YES NO IF YES, describe: A. Identify your primary career objective. Student Career Development Goals/Assessment Are there any other careers that interest you? If so, please list: B. Why do you want to participate in this program? Please include special skills, talents, etc. that qualify you. Student s Signature
4 Parent Information Work-Based Learning Application (To be completed by parent/guardian of applicant) Student s Name Why would your child be a good candidate for the work-based learning program? Parent s/guardian s Signature
5 Work-Based Learning Program Parent/Guardian Consent Form Enrollment Consent: I consent to the enrollment of my son/daughter in the work-based learning program. Transportation Consent: (School-provided transportation to work-based learning work site is not available.) I give my son/daughter permission to drive/car pool to his/her work site. I expressly release the work-based learning work site and the Fulton County School System and any agents of the employer or the school system from any liability that may result from my child s use of his/her individual transportation. YES NO Field Trips/Class Projects: Permission is granted for my son/daughter to participate in field trips and class projects associated with work-based Learning. (Transportation to work-related field trips will be provided by the school system.) YES NO Photo/Media Release: Permission is granted to photograph/videotape/interview my son/daughter for promotional and educational purposes. YES NO Student s Record Release: I authorize the Fulton County School System to release my son s/daughter s academic, discipline, and attendance records to any potential employer, and I agree that the Fulton County School System and its agents will be absolved of any responsibility in connection with such release. This authorization can be cancelled at any time by written notice to the school system representative. YES NO Treatment Consent: I authorize the school or the work-based site employer to secure emergency medical treatment for my son/daughter. YES NO Insurance: Health Insurance Company (If student is not covered by medical insurance, parent/guardian agrees to purchase insurance through the school insurance program.) YES NO Automobile Insurance YES NO Company Screening for Illegal Substance Use: Some employers require prospective employees to participate in drug screening procedures as a condition of employment. I understand that my signature indicates that I have read and understand all of the above information. Parent s/guardian s Signature & Student s Signature &
6 Fulton County School System Work-Based Learning Application Teacher Recommendation Form Student s Name School Counselor The following evaluation grid is provided for those who know the student well enough to give an accurate assessment of him/her. It should provide a convenient method to describe the candidate in summary fashion. Use the rating criteria chart below to rate each trait. Trait Initiative/Motivation Dependability Leadership Self-confidence Responsibility Honesty Effort Flexibility Rating Criteria 5 Consistently Exhibits Trait Always demonstrates trait appropriately: demonstrates predictable responses in all situations 4 Often Exhibits Trait Frequently demonstrates the trait appropriately; Demonstrates predictable responses in most situations 3 Inconsistently Exhibits Trait Erratically demonstrates the trait, sometimes inappropriately; demonstrates predictable responses in some situations 2 Seldomly Exhibits Trait Rarely demonstrates the trait; demonstrates unpredictable responses in most situations 1 Does not Exhibit Trait Never demonstrates trait I recommend / I do not recommend the above student for the work-based program. (circle one) Teacher s Signature Subject(s) Taught If applicable, please attach reasons for any of your ratings to assist us in evaluating the candidate. Return form to:
7 Fulton County School System Work-Based Learning Application Teacher Recommendation Form Student s Name School Counselor The following evaluation grid is provided for those who know the student well enough to give an accurate assessment of him/her. It should provide a convenient method to describe the candidate in summary fashion. Use the rating criteria chart below to rate each trait. Trait Initiative/Motivation Dependability Leadership Self-confidence Responsibility Honesty Effort Flexibility Rating Criteria 5 Consistently Exhibits Trait Always demonstrates trait appropriately: demonstrates predictable responses in all situations 4 Often Exhibits Trait Frequently demonstrates the trait appropriately; Demonstrates predictable responses in most situations 3 Inconsistently Exhibits Trait Erratically demonstrates the trait, sometimes inappropriately; demonstrates predictable responses in some situations 2 Seldomly Exhibits Trait Rarely demonstrates the trait; demonstrates unpredictable responses in most situations 1 Does not Exhibit Trait Never demonstrates trait I recommend / I do not recommend the above student for the work-based program. (circle one) Teacher s Signature Subject(s) Taught If applicable, please attach reasons for any of your ratings to assist us in evaluating the candidate. Return form to:
8 Fulton County School System Work-Based Learning Application Teacher Recommendation Form Student s Name School Counselor The following evaluation grid is provided for those who know the student well enough to give an accurate assessment of him/her. It should provide a convenient method to describe the candidate in summary fashion. Use the rating criteria chart below to rate each trait. Trait Initiative/Motivation Dependability Leadership Self-confidence Responsibility Honesty Effort Flexibility Rating Criteria 5 Consistently Exhibits Trait Always demonstrates trait appropriately: demonstrates predictable responses in all situations 4 Often Exhibits Trait Frequently demonstrates the trait appropriately; Demonstrates predictable responses in most situations 3 Inconsistently Exhibits Trait Erratically demonstrates the trait, sometimes inappropriately; demonstrates predictable responses in some situations 2 Seldomly Exhibits Trait Rarely demonstrates the trait; demonstrates unpredictable responses in most situations 1 Does not Exhibit Trait Never demonstrates trait I recommend / I do not recommend the above student for the work-based program. (circle one) Teacher s Signature Subject(s) Taught If applicable, please attach reasons for any of your ratings to assist us in evaluating the candidate. Return form to:
9 Fulton County School System Work-Based Learning Counselor Sign-Off Sheet Student s Name Home Room Counselor s Name Career Interest Area ( a printout of student schedule can be attached to this sheet instead of completing this section ) Period Class Teacher Room # Check one: On Track for Graduation Off Track for Graduation Please provide the following information: transcript, discipline profile and attendance record. Fulton County School System, Work-Based Learning Program Parent / Guardian Consent Form, has been signed by parent or legal guardian. Counselor s Signature Comments: Please return form to:
10 Work-Based Training Agreement Student s Name Career Pathway Parent/Guardian Employing Company Phone Company Address Supervisor Mentor Work-Based Learning Coordinator Student s Responsibilities Meets all required academic standards for high school graduation Maintains appropriate appearance for the job Abides by all school and work attendance, conduct, and discipline policies Attends school in order to attend work. (Non-attendance at school or work, without reporting to both, will be counted as an unexcused class absence, and the appropriate disciplinary action(s) will apply). Adheres to all terms, regulations, and conditions of the work-based learning program of the work site, and at school Arranges for reliable transportation to and from the work site Work a minimum of 10 hours no more than 20 hours maximum per week to be counted toward class credit Exhibits positive work habits and attitudes on the job and in the classroom Submit to the Work-Based Learning Coordinator a weekly record indicating activities engaged in at the worksite and total hours and salary earned during the week Terminates employment only after consulting with the school system representative Maintains legal United States citizenship to participate in this work-based learning program Student s Signature Parent/Guardian Responsibilities Encourages the student to participate in the program and to carry out his/her duties effectively Encourages good work-based habits and ethics Supports all aspects of the work-based learning program and serves as a resource for the school and the student Cooperates with the school system representative, work-site supervisor, and the school in providing career training Understands that the student must maintain a good attendance record and must attend school in order to report to work Maintains regular communication with school system representative Assists in obtaining student s transportation to the worksite Students must be a legal citizen of the United States to participate in this work-based learning program
11 Allows the release of student records regarding academic performance, attendance, and discipline for the purpose of employment and program follow-up Parent/Guardian Signature Employer Responsibilities Maintains a safe working environment for the student Provides consistent supervision of student Assists the student in acquiring the necessary skills and knowledge required on the job and that contributes to the attainment of his/her career pathway Employs the student for at least 10 hours minimum and 20 hours maximum per week during the academic school year Adheres to policies and practices which prohibit discrimination on the basis of race, color, national origin, sex, and handicap in recruitment, hiring, placement, assignment to work tasks, hours of employment, levels of responsibility, and pay Provides progressive wages to the student for work experience when appropriate Monitors, evaluates, reports student progress and provide time for consultation with the work-based learning coordinator and student to address work behavior a minimum of once per grading period Maintains regular communication with school system representative Adheres to labor mandated restrictions and obtains parent signature as required Verifies the identity and employment eligibility of those hired in this work-based learning program Company Representative Signature School System Representative Responsibilities Screens prospective students Recommends students for program Monitors, evaluates and reports progress and grades of students (minimum 2 visits per semester) Works with counselor to ensure that the student receives no more than two credits to apply toward graduation requirements and only one credit will count toward the student s required courses for career pathway completion. Maintains communication with student, parent and employer Communicates progress and concerns to appropriate school personnel Recruits employment sites Arranges interviews Supervises and problem solves job related issues Initiates and supervises implementation of training agreement/business plan Visits employment sites at least twice per semester and documents each visit School System Representative Signature Please Note the Following: The student shall receive no more than two (2) credits to apply toward graduation requirements. Only one credit will count toward the student s required courses for career pathway completion. The duration of this training period is for one full academic school year. The purpose of the training agreement is to establish a basis of understanding as to what is expected from everyone involved in the WBL placement and to outline the responsibilities of all participating parties.
12 Work-Based Learning Safety Training Agreement, a student in the work-based learning program at High School and an employee at has completed the necessary safety training for the current position of employment. The employer certifies that the proper procedures related to the job requirements have been shown to the student and that in the case of an emergency, the student has been given instructions on what to do to resolve the situation. The student understands that failure to comply with these safety procedures may result in personal injury or in injury to others. The student agrees to follow all the safety rules and regulations of the current employer. Student s signature Parent s signature Employer s signature WBL Coordinator s signature
13 Work-Based Learning Employer Information Student Name: (Last) (First) (Middle) Employer: Company name: Address: (City, State, Zip) Phone: Fax: Contact Person: Supervisor/Mentor: Type of Business: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Business Hours Student Hours Average hours worked each week: Pay per hour:
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