Please enable JavaScript in your browser to complete this form.Note that this is a paid, hands-on learning opportunity designed to provide real-world job shadowing and workforce experience. Some participants may be offered future employment at the contractor’s discretion; however, this is not guaranteed. Full Name *FirstLastAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone number *Do we have permission to contact you VIA text message? *YesNoEmail *Date of Birth (please make sure correct birth year is selected) *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex *_MaleFemaleEthnicity *_Black/African AmericanCaucasianHispanicAsianOtherSchool Status: Current Grade/Graduated/GED *School Currently Attending/Graduated From *Do you have a valid driver's license and reliable transportation? *Yes, I have a valid driver's licenseNo, I do not have a valid driver's licenseYes, I have reliable transportationNo, I do not have reliable transportationHave you ever been convicted of a felony? *_YesNoWhich of the following trades are you most interested in? *ElectricalPlumbingCarpentryMechanical-HVAC (Heating, Ventilation, Air Conditioning)Culinary ArtsPaintingOtherIf you selected more than one trade above, what is your 1st choice? *Days Available to Work *MondayTuesdayWednesdayThursdayFridayList your available times for work, ie: mornings, afternoons, all day or specific time frames *Medical Conditions/Allergies *Emergency Or Parent/Guardian Information Emergency or Parent/Guardian Name *FirstLastPhone *Email *Name of Physician to be called in an emergency *Physician phone number *List the name of a Reference (Not related) *Reference contact number *How did you hear about our program? *Part A: Release/Liability *In case of injury or emergency, I authorize ABC Youth or its representatives to contact emergency services and, if necessary, arrange medical treatment as advised by a licensed healthcare provider. I understand that I am personally responsible for any medical expenses incurred as a result of participation. If the above-named applicant is under 18, as Legal Guardian of said applicant, I am in agreement with these terms and conditions.As a participant in the ABC Youth Work Based Learning Program, I understand that I may be assigned to observe or assist licensed contractors, trades professionals, or partner organizations at active job sites. I acknowledge that these environments may involve the use of tools, machinery, or equipment that present potential risks. If the above-named applicant is under 18, as Legal Guardian of said applicant, I am in agreement with these terms and conditions.I agree to follow all safety instructions and supervision provided by the on-site contractor or ABC Youth staff. I understand that ABC Youth’s role is limited to coordination and supervision of program participation and that ABC Youth, its staff, and volunteers are not responsible for the management, safety conditions, or operations of any contractor’s work site. If the above-named applicant is under 18, as Legal Guardian of said applicant, I am in agreement with these terms and conditions.I understand this is a paid, hands-on learning opportunity designed to provide real-world job shadowing and workforce experience. Some participants may be offered future employment at the contractor’s discretion; however, this is not guaranteed. If the above-named applicant is under 18, as Legal Guardian of said applicant, I am in agreement with these terms and conditions.I hereby give ABC Youth Organization (ABC) and its partners and affiliates consent to use and reproduce my image (if 18 and over) or my child’s first name/image (if under 18) for promotional purposes relate to ABC, and/or external partners, without compensation. My name (if 18 and over) or my child’s first name, if under 18, (unless otherwise authorized)/image may be published or used in newspapers, promotional videos, television commercials, program brochures, posters, on World Wide Web or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by ABC, or external partners. I release ABC and its agents from any and all claims, of any nature, based on any uses of the above.I understand and agree to release, indemnify, and hold harmless ABC Youth Organization/Work Based Learning Program, its officers, staff, volunteers, and partners from any and all claims, damages, or liabilities arising from participation in any ABC Youth Work Based Learning activities, contractor worksite visits, or travel to and from related locations. In consideration of the risk of injury while participating in ABC Youth Work Based Learning Program (the “Activity”), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive and all rights, claims or causes of action of any kind whatsoever arising out of my (if 18 and over) or my child’s (if under 18) participation in the ABC Youth Work Based Learning Program, and do hereby release and forever discharge the ABC Youth Organization/Work Based Learning Program located at 2715 North Averill Avenue, Flint, Michigan 48506, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors, and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I or my minor child may suffer as a direct result of my participation in the ABC Youth Work Based Learning Program, including traveling to and from an event/job site related to ABC Youth Work Based Learning Program. I agree to indemnify and hold harmless the ABC Youth Organization/Work Based Learning Program against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If the ABC Youth Organization/Work Based Learning Program incurs any of these types of expenses, I agree to reimburse the ABC Youth Organization/Work Based Learning Program. I acknowledge that ABC Youth Organization/Work Based Learning Program and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any part or entity conducting a specific event or activity on behalf of ABC Youth Work Based Learning Program.Electronic Signature *FirstLastSubmit
