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Job Shadow Activity Request Form
Job Shadow Activity Request Form
Job Shadow Activity Request Form
Job Shadow Activity Request Form
Use this form to request a Job Shadow Placement. Be sure to complete form thoroughly and completely. You will be contacted with any questions or when the placement has been made.
Name
First
Last
School
*
Anna
Botkins
Christian Academy
Fairlawn
Ft. Loramie
Houston
Jackson Center
Lehman Catholic
Russia
Sidney
Sidney Opportunity School
Grade
*
9th - Freshman
10th - Sophmore
11th - Junior
12th - Senior
Gender
*
Male
Female
School Email Address
*
Personal Email Address
Cell Phone Number
*
(Include area code) Example: xxx-xxx-xxxx. (If you do not have a cell phone, enter 000-000-0000).
Current Age
*
Date of Birth:
*
Include day, month, year: Example: 10-23-2001
Guidance Counselor or Teacher Name:
*
Guidance Counselor or Teacher Email:
*
Career Interest
*
Manufacturing Production
Construction
Electrician
HVAC Technician
Plumbing
Engineering
Mechanic
Nurse
Other: Healthcare
Business Admin
Other
If Other, please specify
I am interested in a specific company. If so, list company below. Specific company placements are not guaranteed.
Is a specific date required by your teacher? If yes, select the exact date below:
MM slash DD slash YYYY
Job Shadowing times vary based on the host company's schedule. Please indicate your availability:
*
Anytime (Between 8 am - 3 pm)
Morning (8 am - Noon)
Afternoon (11 am - 3 pm)
How will you be transported to and from the company?
*
I have a driver's license and will drive myself
Parent/Guardian will transport
Need transportation provided
List any special circumstances to be considered: (physical, personal, activity or work schedule, other):
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