Form Jhda-E1 - Las Cruces Public Schools Employment Certification Form printable pdf download

Form JHDA-E1

Las Cruces Public Schools

Employment Certification Form

Students must be at least seventeen (17) years of age.

Student must have regular gainful employment in a trade or occupation.

When possible, employment should be scheduled in the morning or afternoon only.

Part I – STUDENT INFORMATION

Student___________________________________________________________________ ID Number____________________________

Last

First

⁬

Birth Date_____/_____/_____ Gender:

Grade in School ___________as of August (year)__________

Current School _______________________________

⁬

Parent/Guardian:

Mr.

Mrs./Ms./Miss___________________________________________________________________________

Mailing Address: ________________________________________________________________________________________________

Street

City

State

Zip

Residence Address: _____________________________________________________________________________________________

Street

City

State

Zip

Home phone____/____/____ Cell phone ____/____/____ Work phone ____/____/____E-mail __________________________________

Part II – EMPLOYER INFORMATION

Place of Employment/Employer Name ______________________________________________________________________________

Job title or position_________________________________________________ Hire date_____________________________________

Hours of employment during the school day __________________________________________________________________________

I verify that the above named student is an employee and works the specified hours during the regular school day.

__________________________________________________________________

______/______/______

Employer signature

Date

Part III –CERTIFICATION

The above named student is excused from full time attendance as long as he/she continues to be gainfully employed. If at

any time the student fails to maintain employment, this certificate will be revoked and full-time attendance will be

required.

______________________________________________________________________

___________________________

PRINCIPAL SIGNATURE

Date

______________________________________________________________________

________________________________

PARENT/GUARDIAN SIGNATURE

Date

PART IV- FOR SCHOOL USE ONLY. Employment should be verified prior to signing this form and status should be checked periodically.

EMPLOYMENT VERIFIED BY _________________________________________________________________

_____________________________________

Name/Title

Date

Employment verification checks________________________________________________________________

DATE

LCPS Regulation JHDA-R; JHDA-E1 created 01.09.15

Form Jhda-E1 - Las Cruces Public Schools Employment Certification Form

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