AT&T Program Sign-Up - Challenge House

Name *

First

Last

Address: *

Date of Birth: *

Age:

Phone Number *

What are your top three professional or work interests? (Example: nurse, teacher, mechanic, etc.) *

Can you arrange for transportation to your worksite the second week? *

Have you participated in a Challenge House AT&T class in previous years?

What school do you attend?

What grade going into Fall 2023?

Are you involved with any after school activities at school? Please list below:

Are you a member of any clubs or organizations? Please list below:

Do you have any work experience? If so, please explain

Parent/Guardian Name: *

Parent/Guardian Address:

Email *

Cell Phone

Work Phone

Emergency Phone Number: *

Please list any medical conditions and/or allergies (type n/a, if none): *

Please list any ongoing medications (type n/a, if none):

Please list any other information that you feel we need to know about the student:

Parent/Guardian should be notified to pick up student if student is dismissed from the program? *

Does the student attend any IEP classes? *

Please write an essay (100 words minimum) below explaining why you want to be accepted into the AT&T Work Study Program and what specific jobs might interest you when you become an adult. Please write your essay below or type your essay and attach it to this document. This essay is important, and applicants who write a thoughtful essay may be given an edge toward acceptance into the Program. *