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Student Application (Test)
Student Application (2020-2021)
Step
1
of
5
20%
STEP 1: Personal Info
Student Information
Name
*
First
Last
Email
*
Use your OFFICIAL SCHOOL EMAIL ADDRESS if available.
Cell Phone
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
MM slash DD slash YYYY
Parent / Guardian Information
Name
*
First
Last
Relationship to Student
*
Mother
Father
Guardian
Other
Email
*
Cell Phone
*
Home Phone
STEP 2: Educational Background
High School Type
*
(Select one)
Public School
Private/Independent School
Charter Schools
Home School
Early College
Other
If other, please specify:
*
High School Name
*
(Select one)
Bethany Community School
Carolina Baptist Academy
Community Baptist School
Dalton McMichael High School
John Motley Morehead High School
Reidsville High School
Rockingham County Senior High School
Rockingham Early College High School
Other
If other, please list name here:
*
Grade Level
*
11 (Junior)
12 (Senior)
List any CTE course you are taking/have taken at your current high school:
Please list the name and the year of the course [e.g., Robotics (Fall 2018), 3D Modeling & Animation (Spring 2019), etc.]
STEP 3: Interests & Career Information
Education plans after high school?
*
(Check all that apply)
Apprenticeship
2-Year Degree
4-Year Degree
Are you available for a Pre-Apprenticeship assignment from June to August?
*
Yes
No
Which apprenticeship pathway(s) are you interested in?
*
Advanced Manufacturing
Undecided
Why are you interested in this opportunity?
*
List any school, athletic, volunteer, or community activities.
STEP 4: Employment History (if applicable)
Job #1
Place of Employment
Employment Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Supervisor Name
First
Last
Supervisor Phone
Description of Job Duties
Job #2
Place of Employment
Employment Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employment Start Date
MM slash DD slash YYYY
Employment End Date
MM slash DD slash YYYY
Supervisor Name
First
Last
Supervisor Phone
Description of Job Duties
STEP 5: Program Requirements & Submission
Apprenticeship Program Information
How did you hear about RockATOP (Apprenticeship Program)?
*
(Check all that apply)
Career Development Coordinator
School Counselor
Career Coaches
School Assembly Presentations
Classroom Presentations
Teacher
Parent
Friend
Television
Social Media (Facebook, YouTube, etc.)
School Phone Message
Other
If Other, please list here:
Is there any additional information you would like us to know when considering your application?
Have you submitted a RockATOP application before?
*
Yes
No
Disclaimer
My signature below verifies that the above information is correct. I understand if I am selected for the program, I am responsible for abiding by the policies and procedures of my employer as well as the guidelines for the RockATOP program. I understand that I will be responsible for transportation to and from my work assignment. I understand that I must be eligible for work in the United States. I give permission for the RockATOP program and my employer to review my grades to verify that I am maintaining the standards set by this program.
Consent
*
I agree to this policy.
Student Signature
*
First
Last
Date
*
MM slash DD slash YYYY