Summer Internship Program

Students applying for the paid Summer Employment Program must be able to complete an internship during the summer, meet eligibility requirements which may include income information, and pass a background check and drug screen with the payroll entity. Please complete this information, and you will be contacted by a CareerSource Gulf Coast Case Manager to determine if you are eligible and help you with registration. Feel free to call Linda Cohen at 850-872-4340 ext. 8110 for more information.

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* 1. Address

First and Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Parent/Guardian name

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* 3. Parent/Guardian phone number

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* 4. Parent/Guardian email address

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* 5. Student's Date of Birth

MM/DD/YYYY

Date

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* 6. Name of High School

Other (please specify)

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* 7. Are you graduating in May of 2023?

Yes

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* 8. Will you be entering your Senior year in August 2023?

Yes

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* 9. Are you currently working?

Yes

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* 10. What are your plans after high school?

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* 11. Are you available and able to complete a paid internship this summer (20 - 40 hours per week)?

Yes

Other (please specify)

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* 12. Please answer the questions below

	Yes	No	Unknown
Do you have a family member that did NOT graduate from High School?	Do you have a family member that did NOT graduate from High School? Yes	Do you have a family member that did NOT graduate from High School? No	Do you have a family member that did NOT graduate from High School? Unknown
Have your parents ever been incarcerated?	Have your parents ever been incarcerated? Yes	Have your parents ever been incarcerated? No	Have your parents ever been incarcerated? Unknown
Do you live in a nontraditional household (single parent, live with grandparents, live with unofficial guardian, etc.)	Do you live in a nontraditional household (single parent, live with grandparents, live with unofficial guardian, etc.) Yes	Do you live in a nontraditional household (single parent, live with grandparents, live with unofficial guardian, etc.) No	Do you live in a nontraditional household (single parent, live with grandparents, live with unofficial guardian, etc.) Unknown
Have you ever been involved with the justice system?	Have you ever been involved with the justice system? Yes	Have you ever been involved with the justice system? No	Have you ever been involved with the justice system? Unknown
Are you homeless or a runaway?	Are you homeless or a runaway? Yes	Are you homeless or a runaway? No	Are you homeless or a runaway? Unknown
Are you in foster care?	Are you in foster care? Yes	Are you in foster care? No	Are you in foster care? Unknown
Are you pregnant or parenting?	Are you pregnant or parenting? Yes	Are you pregnant or parenting? No	Are you pregnant or parenting? Unknown
Do you have a disability (including learning disabilities)	Do you have a disability (including learning disabilities) Yes	Do you have a disability (including learning disabilities) No	Do you have a disability (including learning disabilities) Unknown
Do you have a parent in the military that is deployed?	Do you have a parent in the military that is deployed? Yes	Do you have a parent in the military that is deployed? No	Do you have a parent in the military that is deployed? Unknown
Does anyone in your household receive Food Stamps or any other type of public assistance?	Does anyone in your household receive Food Stamps or any other type of public assistance? Yes	Does anyone in your household receive Food Stamps or any other type of public assistance? No	Does anyone in your household receive Food Stamps or any other type of public assistance? Unknown
Do you have a parent that is unemployed, underemployed, or self employed?	Do you have a parent that is unemployed, underemployed, or self employed? Yes	Do you have a parent that is unemployed, underemployed, or self employed? No	Do you have a parent that is unemployed, underemployed, or self employed? Unknown

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* 13. In the past six months, have you worked for the same employer full time (more than 30 hours per week)?

Yes

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* 14. Do you have the following?

	Yes	No
Reliable transportation	Reliable transportation Yes	Reliable transportation No
A valid driver's license	A valid driver's license Yes	A valid driver's license No
Valid car insurance	Valid car insurance Yes	Valid car insurance No
Have your own car	Have your own car Yes	Have your own car No