Southeastern Community College


The Link Job Shadow Application

* denotes required information.

* First Name:

* Middle Initial: enter 'X' if no middle initial

* Last Name:

* E-Mail Address:

* Street:

* City:

* State:

* Zip:

* Phone:  Please include area code, and enter only numeric digits. Example 3197522731

* Date Of Birth:

* School District Name:

* Grade Level:

* Gender: Male    Female

* Is this a requirement for your class? Yes    No
If so, what class:

  Check here if you have an IEP or 504 plan.

Please list up to three career choices that interest you:

  Career Choice 1:

  Career Choice 2:

  Career Choice 3:

What topics or classes interest you the most at school?

What are your plans after school?

Do you have any volunteer or work experience?

Parent/Guardian must complete the remaining information if the job shadow request is NOT for a class.

Parent/Guardian Information

First Name:

Middle Initial: enter 'X' if no middle initial

Last Name:

Relationship:

E-Mail Address:

Street:

City:

State:

Zip:

Phone:  Please include area code, and enter only numeric digits. Example 3197522731

Participation and Media Release

I am the parent or guardian of the student whose name appears above and I have authority to make legal decisions for the benefit of this child.

I recognize that work-based learning opportunities of this nature have a risk of lost or stolen property, injury or even death during transportation to, from, on-site, and during the activities. I, on behalf of the child and for myself, waive any and all claims of liability arising from the child's participation in this opportunity, including claims against the following parties (and their employees, contractors, and volunteers): Southeastern Community College, the school and school district that the child attends, and the employer who hosted the work-based learning opportunity.

I agree to defend, hold harmless, and indemnify Southeastern Community College, the school, and the school district that the child attends, and the employer who hosted the trip (and their employees, contractors, and volunteers) from and against any and all claims of liability that derive from claims that I or my child make against any other parties from this work-site opportunity.

I give my consent to have Southeastern Community College staff member contact my son or daughter at some future date to review their career development.

Media: I agree to allow my child's photograph, video tape or motion picture image that includes his/her name or likeness or any recording that includes his/her voice to be used in marketing materials to promote The Link at Southeastern Community College. I understand that my child's photo/image will only be used in a positive manner in publications, print advertising, promotional materials or any other medium to inform others about the career exploration activities coordinated by The Link and the school districts.

Yes - I will allow my child's image/comments to be used by Southeastern Community College.
No - I will not allow my child's image/comments to be used by Southeastern Community College.

Parent Name:


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