Student Data Sheet Template
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1
2
3Date Received _____________________
Entered into Database ___________________
Background Check: O
O
OK
/
NOT OK
STUDENT DATA SHEET
Name: ________________________________________________________ Date: _____________
First Name
Middle Name
Last Name
Address: ___________________________________________________ WI____________________
Number
Street
City
State
Zip
Home Phone: (___) ____-_____ Work Phone: (___) ____-_______ Cell Phone: (___) ____-______
E-mail address: ___________________________________________________________________
Emergency Contact: ________________________ Phone Number: (___) ____-_______
Do you drive?
Yes
No
Is car available for use?
Yes
No
Driver’s License No.: ______________________________________________ State: ____________
Please indicate what kind of opportunity you are interested in:
Service Learner
Internship
Current School: ______________________________ Degree in progress: _____________________
Educational Background: ____________________________________________________________
Certification(s): ____________________________________________________________________
Occupation: _____________________________________ Employer: ________________________
Previous intern/service learner experience:
(where, when, what)
________________________________________________________________________________
Relevant Skills: ___________________________________________________________________
________________________________________________________________________________
Relevant Coursework: ______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
FORM595B - Student Data Sheet
(1,3)
11/14
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Parent category: Business