Name of Student *

First Name

Last Name

What day was the student absent or tardy? *

MM

DD

YYYY

Name of Parent or Guardian *

First Name

Last Name

Name of parent *

First Name

Last Name

Phone Number of Primary Mentor (Please provide a number where staff and students can reach you. *

(###)

###

####

Q5. I will accept a student intern with the following experience level (select all that apply or type in other, if different.) *

No previous work experience needed

No previous work experience in this field needed

Any age 14-18

Other

Please check all the following to confirm that you agree to and will provide these things for Linville Hill Christian School's internship program: *

I will submit all clearances.

I will provide signatures on all necessary documents required by the program.

I will be present during the student's site visit and provide feedback to school staff.

I will complete a final Performance Evaluation for the student.

I will provide a meaningful educational internship for 12 full day Fridays.

I will maintain a record of the interns days and hours.

I will approve and sign the student's hours log at the end of the internship period.