NAME:

ADDRESS:

CITY: STATE: ZIP:

TEL. NO.: DATE OF BIRTH:

PARENT(S) OR GUARDIAN(S) WITH WHOM YOU LIVE:

FATHER’S OR GUARDIAN’S PLACE OF EMPLOYMENT AND TELEPHONE NUMBER:

MOTHER’S OR GUARDIAN’S PLACE OF EMPLOYMENT AND TELEPHONE NUMBER:

LIST BRIEFLY THE HOBS YOU HAVE HAD SINCE YOU HAVE BEEN IN HIGH SCHOOL.

EMPLOYER: JOB PERFORMED: DATES WORKED:

HAVE YOU EVER BEEN DISMISSED (FIRED) BY AN EMPLOYER? IF YES, PLEASE EXPLAIN.

STATE BRIEFLY THE REASON YOU ARE APPLYING FOR THE INTERNSHIP PROGRAM:

DO YOU PLAN TO ATTEND COLLEGE? WHAT DO YOU PLAN TO STUDY?

______________________________________________________________________________________

LIST BELOW NAMES, COMPLETE ADDRESSES AND TELEPHONE NUMBERS OF TWO TEACHER REFERENCES WHO KNOW YOU WELL ENOUGH TO GIVE ADDITIONAL INFORMATION REGARDING YOUR CHARACTER AND ABILITY. DO NOT LIST RELATIVES.

1. TEL:

2. TEL:

LIST BELOW NAMES, COMPLETE ADDRESSES AND TELEPHONE NUMBERS OF TWO ADULT REFERENCES WHO KNOW YOU WELL ENOUGH TO GIVE ADDITIONAL INFORMATION REGARDING YOUR CHARACTER AND ABILITY. DO NO LIST RELATIVES.

1. TEL:

2. TEL:

**************************************************************************************

PARIS HIGH SCHOOL

TRANSCRIPT RELEASE FORM

I, , request that Paris High School provide a copy of my transcript to Mr. Mark Thomas as director of the Internship Program. I give my permission for Mr. Thomas to make copies of my transcript, application and resume, and give them to prospective participating business partners who may consider me for an internship under the Paris High School Internship Program. Mr. Thomas may discuss my application, resume and other information with prospective business partners. Parent/guardian signature also gives permission for the student to leave school campus during the school day for interviews. Parent/guardian is responsible for all transportation and assumes all liability and responsibility for the student.

What is your GPA? ______. How many days were you absent last semester? ________.

Application and Transcript Release Form Approved By:

__________________________________ _______________________________

Signature of parent or Guardian Signature of Student

Today’s Date:

Please return to Mr. Thomas’s office (Guidance). THIS FORM MUST BE COMPLETE OR YOUR APPLICATION WILL NOT BE CONSIDERED. In addition, the student MUST ALSO SUBMIT A RESUME. The student’s past attendance, grades and discipline record will also be considered in reviewing his/her application. The student must have passing grades in all subjects during the semester preceding placement in the program. Grades of C or better in all subjects are generallly expected.

“Paris Union School District #95 does not discriminate on the basis of gender, color, race, age, national origin or disability.”

COOP04-05:INTERNapp