ICE Employment Application Questionnaire
ICE Employment Application Questionnaire Read the guidelines and complete the attached application. ICE is a three period requirement, one period of which is classroom instruction and two periods of which are periods to leave school early and go to work. Application Guidelines: 1. If you are able to answer YES to ALL the following questions, please continue reading. If not, you do not qualify for the program and will need to show improvements in those areas before applying: a. Will you complete Core 40 classes by the end of your senior year? b. Is your attendance rate at 85% or higher this past semester? c. Are you maintaining a GPA of 1.5 of 4.0? d. Is your discipline record clear of any referrals? If not, how many referrals have you had? _______ e. Are there three school personnel who would give you an outstanding recommendation? f. Do you have transportation to the work site? g. Are you currently an employee of the company where you will work from August to May? If not, what is your plan to be employed before August? 2. When completing the application, please print neatly using BLUE or BLACK ink. 3. A parent/guardian signature is required even if you are 18 years old. 4. Complete the ICE Application and return it to Guidance by: Wednesday, February 15th I agree to work from August through May at: _______________________ If I intend to change my place of employment, I will have a conversation with Mrs. Kroll (Internship Coordinator) prior to leaving the above employer. ______________________________ Student Signature ______________________________ Student Printed Name
I.C.E. Application Mooresville High School (Print neatly in blue/black ink)
Due to Guidance by February 15th Student Last Name:
Student First Name:
Student Middle Initial:
Street Address:
Gender: M
City:
State:
F
ZIP: INDIANA
Home Phone:
Student Cell Phone:
(___ ___ ___) __ __ __ - ___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ __
Email address: Student E-MAIL
Date of Birth: ___ ___ / ___ ___/ ___ ___
Unexcused Absences (current year)
Verified GPA (as of last term)
DID YOU PASS THE ECA? Yes Or No
Is it OK to text you? YES Or NO Age as of August 1 2016____________ Graduation Year:
If NO, Which do you still need to pass: ENGLISH or MATH
List three school personnel references (teachers, guidance, and/or administrators) that the Internship Coordinator should consult for references. 1.______________________________
2.______________________________
3.______________________________
Add any other information that you would like to share that you think would be useful in the decisionmaking process of acceptance for the ICE Program. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ The Student-Learner agrees to: 1. I UNDERSTAND THAT I WILL BE TURNING IN MY PAYCHECK STUBS/WEEKLY REPORTS AND ALSO COMPLETING ON SITE VISITS THAT WILL BE SCHEDULED WITH COORDINATOR (One Site Visit Per Semester)! I understand that there are midterms and final exams that contribute to my ICE Grade! 2. Abide by the regulations and policies of the business and the school; 3. Attend the related class as required 4. Provide transportation to and from the assigned internship site; 5. Notify the internship coordinator and the site supervisor/mentor on days absent or late prior to starting time (when possible); 6. Not report to the work site on days absent from school; 7. File complete weekly reports on his/her activities as required; 8. Report to the internship coordinator as soon as possible when problems arise affecting his/her placement;
9. 10. 11. 12. 14. 15.
Study the student handbook and accept the conditions set forth therein; Not hold the internship site liable for accidents or injuries sustained during training; Dress appropriately for the school-related program as well as the internship; Provide proof of medical and automobile insurance and a valid driver's license; Refrain from using a personal cell phone for text messaging and/or personal calls; Keep all matters confidential.
**16. The Internship Coordinator (and School Administrators) reserves the right to deny ANY placement for ANY reason. NOTE: The student, business, and parents must be aware that one of the requirements of ICE is that the student must maintain 15 hours of work per week (135 hours per 9 weeks). This will be verified by turning in pay check stubs to the internship coordinator. I understand that if I do not comply with ALL rules and regulations then I will be removed from the program and my grade will reflect the removal. (Including the school’s attendance policy,
which states that if the student has over 10 days of absences they can be removed from the program.) I understand that I must provide my own transportation to and from the work site before I can be considered for the ICE Program. I also understand that I will commit to the program for the entire year, accepting all the responsibilities placed upon me in the related class and on the job. __________________________________ Student Signature
_____________ Date
I understand the rules and obligations of the ICE Program and shall do my part to assist my son/daughter in fulfilling all obligations of the program. __________________________________ Parent/Guardian Signature
_____________ Date
It is the policy of the Mooresville High School not to discriminate on the basis of race, color, religion, gender, veteran status, national origin, age, limited English proficiency, or disability in its programs or employment policies as required by the Indiana Civil Rights Law (I.C.22-9-1), Title VI (Civil Rights Act of 1964), the Equal Pay Act of 1973, Title IX (Educational Amendments), and Section 504 (Rehabilitation Act of 1973).
ICE STUDENTS MUST BE EMPLOYED PRIOR TO BEING CONSIDERED!! FOR OFFICE USE ONLY! (Please list any special circumstances or issues associated with student or placement) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
I.C.E. Application Mooresville High School (Print neatly in blue/black ink)
Due to Guidance by February 15th Student Last Name:
Student First Name:
Student Middle Initial:
Street Address:
Gender: M
City:
State:
F
ZIP: INDIANA
Home Phone:
Student Cell Phone:
(___ ___ ___) __ __ __ - ___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ __
Email address: Student E-MAIL
Date of Birth: ___ ___ / ___ ___/ ___ ___
Unexcused Absences (current year)
Verified GPA (as of last term)
DID YOU PASS THE ECA? Yes Or No
Is it OK to text you? YES Or NO Age as of August 1 2016____________ Graduation Year:
If NO, Which do you still need to pass: ENGLISH or MATH
List three school personnel references (teachers, guidance, and/or administrators) that the Internship Coordinator should consult for references. 1.______________________________
2.______________________________
3.______________________________
Add any other information that you would like to share that you think would be useful in the decisionmaking process of acceptance for the ICE Program. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ The Student-Learner agrees to: 1. I UNDERSTAND THAT I WILL BE TURNING IN MY PAYCHECK STUBS/WEEKLY REPORTS AND ALSO COMPLETING ON SITE VISITS THAT WILL BE SCHEDULED WITH COORDINATOR (One Site Visit Per Semester)! I understand that there are midterms and final exams that contribute to my ICE Grade! 2. Abide by the regulations and policies of the business and the school; 3. Attend the related class as required 4. Provide transportation to and from the assigned internship site; 5. Notify the internship coordinator and the site supervisor/mentor on days absent or late prior to starting time (when possible); 6. Not report to the work site on days absent from school; 7. File complete weekly reports on his/her activities as required; 8. Report to the internship coordinator as soon as possible when problems arise affecting his/her placement;
9. 10. 11. 12. 14. 15.
Study the student handbook and accept the conditions set forth therein; Not hold the internship site liable for accidents or injuries sustained during training; Dress appropriately for the school-related program as well as the internship; Provide proof of medical and automobile insurance and a valid driver's license; Refrain from using a personal cell phone for text messaging and/or personal calls; Keep all matters confidential.
**16. The Internship Coordinator (and School Administrators) reserves the right to deny ANY placement for ANY reason. NOTE: The student, business, and parents must be aware that one of the requirements of ICE is that the student must maintain 15 hours of work per week (135 hours per 9 weeks). This will be verified by turning in pay check stubs to the internship coordinator. I understand that if I do not comply with ALL rules and regulations then I will be removed from the program and my grade will reflect the removal. (Including the school’s attendance policy,
which states that if the student has over 10 days of absences they can be removed from the program.) I understand that I must provide my own transportation to and from the work site before I can be considered for the ICE Program. I also understand that I will commit to the program for the entire year, accepting all the responsibilities placed upon me in the related class and on the job. __________________________________ Student Signature
_____________ Date
I understand the rules and obligations of the ICE Program and shall do my part to assist my son/daughter in fulfilling all obligations of the program. __________________________________ Parent/Guardian Signature
_____________ Date
It is the policy of the Mooresville High School not to discriminate on the basis of race, color, religion, gender, veteran status, national origin, age, limited English proficiency, or disability in its programs or employment policies as required by the Indiana Civil Rights Law (I.C.22-9-1), Title VI (Civil Rights Act of 1964), the Equal Pay Act of 1973, Title IX (Educational Amendments), and Section 504 (Rehabilitation Act of 1973).
ICE STUDENTS MUST BE EMPLOYED PRIOR TO BEING CONSIDERED!! FOR OFFICE USE ONLY! (Please list any special circumstances or issues associated with student or placement) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
