Youth Employment Services Enrollment Form

Job Match and Employment Skills Program
New Registration
Re-registration
 Date:
Grade:
Name:
Homeroom:
Zip:
City:
Address:
School:
County:
Ph #(s):
E-Mail:
Female:
Male:
DOB:
Age:
Please mark the days and hours
you are available to work:
Please number from 1-5, in order of preference,
which types of jobs you are interested in:
Child care
Yard work
Carpentry
Elder care
Retail
Restaurant
 Pet care
Stock work
Office work
Housework/cleaning
Lifeguard
Other
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
If you checked
other, please explain
your interests:
Do you have any special certifications or training that would be applicable to your job?
Do you have a driver's license?
Do you have transportation available to you?
What are your current or anticipated after school activities?
Please list any previous work experience, including length and dates of employment.
Do you have any special skills or hobbies?
How did you hear about CHS' Youth Employment Services?
Student signature:
PARENTAL CONSENT(required if youth is under 18)                
                                       
I,
, parent/guardian of
hereby consent to my child's participation in the Job Match/Employment Skills
Program(s).  I understand that my child's telephone number and/or e-mail address may
be given to potential employers.
Parent/guardian signature:
Program funding sources require CHS to collect demographic information about families
served.  Please help us by providing the following information.  Your cooperation helps
CHS secure the resources needed to operate our programs.  Total number of people in
household:
ESTIMATED ANNUAL HOUSEHOLD INCOME
       Please check
ETHNICITY:
Less than $25,000

$25,000 - $34,999

$35,000 - $49,999

$50,000 - $74,999

$75,000 - $99,999

$100,000 - $149,000

$150,000 or more
White

Black

Hispanic

Asian

Native American

Other
CLICK HERE TO SUBMIT THIS
INFORMATION TO PROGRAM
COORDINATOR, COLLEEN LUCIER