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First Name:
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Last Name:
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Street Address:
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Town:
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State:
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Zip:
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Home Phone #:
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Date of Birth:
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Cell Phone #:
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Email Address:
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Year of Graduation:
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Home Room #:
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1st Period Room #:
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Student ID:
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Study Periods and Study Rooms:
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Parents/Guardians' First Name:
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Parents/Guardians' Last Name
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Street Address:
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Home Phone #:
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Work Phone #:
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Guidance Counselor:
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Career Interest:
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Courses you have taken related to this interest:
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Courses currently enrolled in:
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Hobbies, Interest, ect.:
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Plans after high school:
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Do you have transportation?
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Yes
No
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Do you have any limits on your transportation (days of the week, time of day, must have an adult, etc.)?
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Employer/Company Name:
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Address:
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City:
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State:
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Zip Code:
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Phone #
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Period of Employment: (Month/Year to Month/Year)
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Duties:
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School/Volunteer Activities:
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Which choice is your 1st for when to take the internship class?
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Which choice is your 2nd for when to take the internship class?
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Which choice is your 3rd for when to take the internship class?
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Describe past interest in this career and why you want to intern in the field:
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