IVYTECHCOMMUNNITYCOLLEGE

INTEGRATED TECHNOLOGY EDUCATION PROGRAM

Work-Based Learning Program Application

A resume needs to be submitted with this application

(For resume assistance, contact Jennifer Hughes, ITEP Program Advisor, (765)459-0561 ext. 283)

Personal Information

Last Name ______First Name ______M.I. ______

Permanent Address______Student ID # ______

City ______State ______Zip ______Contact Phone ______

Email Address ______

Citizenship Status (check one): ?USA ?Permanent Resident ?Student Visa (Type: ______)

Academic Information

Date of Graduation ______20______Program______Concentration ______

Academic Advisor ______Cumulative GPA ______Previous Semester GPA ______

Pre-Work-based learning Seminar: ?Completed: If so, date completed ______?Not Completed

Work-Based Learning Course Number ______Number of Credits Requested ______

Placement Information

General type of Position Desired ______

On reverse side of this sheet, please expand on what type of experience you want.

Term for Participation: ?Fall 20_____ ?Spring 20_____ ?Summer 20_____

Time Commitment: ?Full-time ?Part-time Total Hours ______

Expectation of Compensation: ?Unpaid ? Paid

Do You Have a Definite Contact for Your work-based learning experience? ?Yes?No; If so, whom______

Supplemental Information

?Yes ?No Do you have your own car?

?Yes ?No Do you intend to hold another job (work-study, part-time) during the work-based learning assignment?

?Yes ?No Are you able to comply with regular attendance expectations as well as meet any otherreasonable expectations of the work-based learning site?

Agreement

I understand that this work-based learningexperience is offered by Ivy Tech Community College through the ITEP program as a curriculum option and is thereby taken for academiccredit, requiring my completing academic assignments. I also understand that this experience is paid for through the Youth CareerConnect grant. If I have a disability or limitation, Iagree to release to the work-based learning site any necessary information that would enable the work-based learning site to provide reasonableaccommodation for my participation in awork-based learning experience. I certify that I personally have completed this applicationandthat the information I am providing is complete, accurate and given in good faith.

Signature: ______Date: ______

IVYTECHCOMMUNNITYCOLLEGE

SCHOOL OF TECHNOLOGY

Work-based learning Program Application (page 2)

Explanation of Position/Experience Desired

Comment briefly on the type of experience you prefer (e.g. your expectations, type of organization and/or industry,type of work you prefer to do, and geographic location preference):

Learning Objectives

Comment briefly on what you most want to learn from this experience. What new knowledge and/or skills do youwish to obtain?

Work Experience (if any)

Names and Locations of Employers / Title/Description of Work / Dates
From / To

Related Coursework

List courses of training you have had that relates to your career field / Credit / Grade / Year

I authorize IvyTechCommunity College to provide employers with the information contained in my student files.

Student and Parent Signature:Date:

High School OfficialApproval:Date:

ITEP Representative Signature:Date:

For questions or concerns regarding your application, please contact Jennifer Hughes, ITEP Program Advisor,765-459-0561, Ext. 283.Application should be returned to Jennifer Hughes, ITCC, 1815 E. Morgan St., Kokomo, IN 46903-1373