Black/African American Native Hawaiian/ Pacific Islander Name Mother’s Address (if different) Number Street City State Zip Contact Number E-mail Address Name Father’s Address (if different) Number Street City State Zip Contact Number E-mail Address CUSTODIAN/GUARDIAN Both Parents Mother Father *** Other/Legal Guardian Living with: ***If custodian/guardian is not the parent legal court documentation must be provided and submitted*** Final placement into this career program will depend upon the Individual Education Plan (IEP) Meeting and the selection committee. A two-week trial period will be required of all accepted enrollees. The student will seek competitive employment before the end of the 2019-2020 school year. Student records concerning the applicant may be transferred to Great Oaks from his/her Affiliated School for review by professional staff. Parent/Guardian Signature Date Student Signature Date EMPLOYMENT BACKGROUND: List jobs or volunteer work you do or have done in school or in the community Employer/Organization Address Number Street State Zip Dates Start Date End Date Supervisor Job Title and Duties Contact Number ☐ ☐ Paid Unpaid Employer/Organization Address Number Street State Zip Dates Start Date End Date Job Title Supervisor and Duties Contact Number
Black/African American Native Hawaiian/ Pacific Islander Mother’s Name Address (if different) Number Street City State Zip Contact Number E-mail Address Father’s Name Address (if different) Number Street City State Zip Contact Number E-mail Address CUSTODIAN/GUARDIAN Both Parents Mother Father *** Other/Legal Guardian Living with: ***If custodian/guardian is not the parent legal court documentation must be provided and submitted*** Final placement into this career program will depend upon the Individual Education Plan (IEP) Meeting and the selection committee. A two-week trial period will be required of all accepted enrollees. The student will seek competitive employment before the end of the 2019-2020 school year. Student records concerning the applicant may be transferred to Great Oaks from his/her Affiliated School for review by professional staff. Parent/Guardian Signature Date Student Signature Date EMPLOYMENT BACKGROUND: List jobs or volunteer work you do or have done in school or in the community Employer/Organization Address Number Street State Zip Dates Job Title and Duties Start Date End Date Supervisor Contact Number ☐ Paid ☐ Unpaid Employer/Organization Address Number Street State Zip Dates Job Title and Duties Start Date End Date Supervisor Contact Number
ps-application-2019-2020-final.docx