Name *

First Name

Last Name

Phone *

(###)

###

####

Availability *

Please check all days and times that you are available

Mondays 9:30am-2:30pm

Tuesdays 9:30am-2:30pm

Wednesdays 9:30am-2:30pm

Thursdays 9:30am-3pm

Thursdays 3:00pm-10:00pm

Fridays 9:30am-3:30pm

Fridays 3:30pm-8:00pm

Fridays 8:00pm-2:00am

Saturdays 8:00am-3:30pm

Saturdays 3:30pm-10:30pm

Saturdays 8:00pm-2:00am

Sundays 8:00am-3:00pm

Intern- Based on your own availability

Reference #1 *

First Name

Last Name

Reference #1's Cell Phone # *

(###)

###

####

Reference #2

First Name

Last Name

Reference #2's Cell Phone #

(###)

###

####

Are you 19 years or older? *

Yes

No

Job Training Program *

While in school, I participated in job training programs such as Work Experience or OJP

As an adult, I've participated in community-based job training programs (Ex: Voc Rehab)

I've participated in both school and community job placement programs

I have not participated in any job training programs - only job-specific orientation and training provided by the company after I am hired

Unsure/prefer not to answer

Applying for family internship - mixed experiences

Mentor *

I have mentored co-workers before in other jobs

I've never mentored co-workers, but I would like to learn more about this opportunity

I like having a mentor or job coach while at work

Unsure/prefer not to answer