Date
Teacher
Home
School District
Student
Name
Student
Address
City
State
ZIP
Phone
Date of
Birth
SSN
Parent/Guardian Name
Anticipated Year of Exiting
Driver's License
Permit
Access to
Transportation
Allergies, Medical Concerns, Limitations
If "Yes", please describe:
Attendance Record for 20 Consecutive School
Days Prior to Interview:
Period Beginning
and ending
.
Class absences
(illness, doctor, in/out of school suspension).
Tardiness (#
of times).
Absence Notification (# of times).
Punctuality (rating by teacher according to
rubric).
Realistic Areas of Interest for Work-Study
Position:
Realistic Areas of Interest for Employment
After Graduation:
Leisure/Recreational Interests:
Personal Assets in Regard to Work, School,
Community, and/or Home:
Personal Limitations in Regard to Work,
School, Community, and/or Home:
Your Name
Your Phone
and/or Email
