Intern Application

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South Bend Community School Corporation
Special Education Services
INTERN Application
"Training that Works"
This application MUST be attached to the current IEP
Date:
School:
Current Grade:
2/25/0205
Wonderful High School
2/25/0205
SBCSC ID#:
Date of Birth:
Name:
170426
Bloggs, Bert
1/14/1986
Address:
City:
State:
Zip Code:
1704 Virginia Avenue
South Bend
IN
46628
Eligibility
SSN:
Phone:
574/234-1752
316-48-2345
Emergency Contact:
Previous Experience: (Use back of the sheet if necessary)
1. Job Shadowing
Yes
No
If Yes, where/when:
2. Job Training (other and INTERN)
Yes
No
If Yes, where/when:
3. INTERN Training
Yes
No
If Yes, where/when:
4. Paid Work
Yes
No
If Yes, where/when:
INTERN Training Choices (Circle your top choices)
AM
PM (Circle session preferred)
Child Care
Retail
Nutrition/Food Services (Specify)
Food Services
Clerical
Laundry
Food Preparation
Warehouse
Grounds
Dining Room
Housekeeping
Social Services
Dish Room
Maintenance
Teacher of Record:
TOR Telephone:
Martha Expert
Does this student need a lift bus?
Yes
No
Is a bus aide required in the current IEP?
Yes
No
Please complete ALL sections of this application. Previous experiences help INTERN staff in determining student
readiness. The information requested is needed to make the best possible match of the student to the INTERN
training site.
Additional Comments:
SBCSC IEP Effective Dates:
South Bend Community School Corporation
Special Education Department

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