Appendix T: Work-Based Learning Student Information

DO-IT Work-Based Learning Student Information

 

Name: __________________________________________ Date:____________________

Gender: _____________ Age: ____________

Racial/Ethnic Identification (check all that apply):

• White, non-Hispanic
• Black, non-Hispanic
• Hispanic
• Asian or Pacific Islander
• American Indian or Alaskan Native

Permanent Mailing Address: ______________________________________________
_________________________________________________________________________
_________________________________________________________________________

Email: _________________________ Phone: ___________________

• day
• eve
• cell

School Attending: ___________________

• High school
• 2-yr college
• 4-yr coll./univ.

Current Grade or Year in School: ____________ Expected Graduation Year: _______________

Describe academic area(s) of study you are pursuing or interested in pursuing (e.g., major).

Describe career(s) you are interested in pursuing.

List any paid or unpaid work experience(s) you have had.

Employment Status:

• employed, full-time
• employed, part-time
• not employed

If employed, name company: ____________________ Position: ________________________

Your Disabilities: _______________________________ Age of Onset: ____________________

Indicate in which of the following areas you would like assistance.

• Explore career interests.
• Learn about legal rights regarding ADA and employment.
• Locate college programs that support career goals.
• Locate campus/school resources (e.g., Career Center, Disabled Student Services).
• Locate community resources (e.g., SSI, Voc Rehab).
• Develop application cover letter for job application.
• Develop/update résumé.
• Gain experience to enhance résumé.
• Develop strategy for disclosure of disability.
• Develop/practice accommodation strategies.
• Assess ability to perform job functions and/or productivity level.
• Develop independent living skills.
• Develop interpersonal skills.
• Develop communication skills.
• Develop public speaking or presentation skills.
• Expand experience with technology.
• Expand use of adaptive technology.
• Develop career networking contacts and/or referrals.
• Prepare for job interviewing.
• Make money.
• Other