First Name              Last Name         

Telephone number              973-555-1212

Social Security #              -             -          

Are you currently employed?

  Yes         No

Employment history:

    Current employer          Ex.  None if not employed or "Shop Rite"

    Previous employer          

    If currently employed, do you have working papers?    yes        no

Do you have reliable transportation from school to work?

      Select one Yes No

Do you have a valid drivers license?

  Yes        No           Drivers license number                                  

    If No, when will you be taking your driving test?

              Select Month September October November December January February March April May

Why do you want to enroll in this Cooperative Education course?

What are your plans after graduation?

   2 or 4 year college                                  Technical school

  Armed forces                                           Full-time employment

  Undecided

Who is your guidance counselor?

Please list two teachers from VTHS as references.  (you do not have to ask permission to use any VTHS teacher)

1st teacher reference           

2nd teacher reference           

How many days were you absent from school this year?

1-4 days          5-9 days         10-15 days          16-20 days          20+ days

Is your graduation status dependent on the 15 credits from this course?

  Select one Yes No

Have you passed the HSPA:

     Language Arts         yes      no

     Math        yes      no

Are you on credit retrieval?

       No                        Yes

Will you have senior status in after finishing junior year?

              Choose one Yes No

Are you involved in any VTHS team sports?

             Yes                              No

Check all that apply:

 

 

Thank you for your interest in the Cooperative Education program. 
We will notify you sometime over the summer to inform you of your status.