EmailMe Form - SDCCD Work Experience Application

COURSE INFORMATION

For the satisfactory completion of all types of Work Experience Education, students may earn up to a total of 16 semester credit hours. Title 5, Section 55253.

View the Work Experience Class List to determine the appropriate course to take based on your placement, hours, and certificate/degree requirements.

Campus: *

City

Mesa

Miramar

Academic Term & Year: *

Work Experience Course: *

Work Experience credit is awarded based on 75 hours of paid work/internship or 60 hours of unpaid internship per unit the student is enrolled. View the Work Experience Student Handbook (Page 13) for minimum hours required per semester by unit.

STUDENT INFORMATION

Student Name *

First Last

CSID: *

Student Phone: *

### - ### - ####

Student Email: *

Prior Work Experience Units Completed: *

Declared Major: *

Are you seeking work experience credit for your own business? *

Yes

No

If Yes, please contact the Mesa College Work Experience Coordinator at sfawcett@sdccd.edu for additional steps and approval.

Are you an international student? *

Yes

No

If YES, please contact the Mesa College Work Experience Coordinator at sfawcett@sdccd.edu for additional steps and approval. Note: International students are required to attend the International Student Orientation, Employment Workshop, submit a CPT checklist, and update your I-20 in order to enroll in Work Experience.

Are you a Veteran student? *

Yes

No

If YES, please contact a Veteran Counselor and/or Veteran Services to understand how enrolling in a Work Experience course may impact your education plan and/or VA benefits.

Are you under 18 years of age? *

Yes

No

If YES, please contact the Mesa College Work Experience Coordinator at sfawcett@sdccd.edu for additional steps and approval. Note: A certified Work Permit will be required for students under 18 years of age.

EMPLOYMENT/INTERNSHIP/VOLUNTEER INFORMATION

Type of Work: *

Paid

Unpaid

Position Title: *

How long have you worked with this organization? *

Note: If you are just starting work for this company, please indicate "0".

How long have you worked in this position? *

Note: If you are just starting work for this company, please indicate "0".

Main Duties/Assigned Responsibilities: *

For this position do you:

Operate a company vehicle? *

Yes

No

Operate heavy equipment? *

Yes

No

(ie: forklift, bulldozer, press machinery)

Work with hazardous materials? *

Yes

No

Work with minors? *

Yes

No

Work in a private residence? *

Yes

No

If you answered YES to any of the above questions, please provide additional details of your position responsibilities:

Work Schedule (ie: 9:00am-12:00pm - Enter 0 (zero) if no shift hours for the day. Schedule can vary each week - Provide an anticipated schedule) *

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Average Total Hours Per Week
Shift Hours (am/pm)

ORGANIZATION INFORMATION

Company Name: *

Address: *

Worksite Address:

(if different than company address)

Site Supervisor Name: *

Site Supervisor Title: *

Site Supervisor Phone: *

### - ### - ####

Site Supervisor email: *

REQUIRED FORMS

The following forms must be completed in order to submit a Work Experience Application and to receive approval to obtain an ADD code to enroll.

Work Experience Quiz - File Upload *

View the Online Work Experience Orientation and upload completed Work Experience Orientation Quiz. Upon completion of the quiz, save as a PDF with a file name that includes your first and last name, WE Quiz, and term/year (ie: John Doe - WE Quiz - Spring 2019). Upload saved file into the online Work Experience Application. This quiz is required to receive an ADD code.

Online Work Experience Orientation

Work Experience Orientation Quiz

Sexual Harassment Prevention Training - File Upload *

Complete the Sexual Harassment Prevention Training and upload report as proof of completion (Part 1 only).

Sexual Harassment Prevention Training

CHIL 270 Immunization Record - File Upload

Immunization Verification - Only required of students interested in enrolling in co-requistes CHIL 270 (CRN # 94864) and CHIL 151 (CRN # 82921). These class sections must be taken together. Complete and upload the Child Development Vaccination Form as proof.

Child Development Vaccination Form

21st CENTURY WORKPLACE SKILLS PRE-WORK EXPERIENCE SELF-EVALUATION

Work Experience is designed to help students develop professional skills through hands-on experience. Evaluate your current performance/ability of each of these 21st Century workplace skills prior to beginning your Work Experience. Ratings of student performance of each skill will be shared with your Work Experience Instructor and Site Supervisor to be discussed at the beginning and end of your Work Experience.

Evaluate your level for each of the following 21st Century workplace skills: *

	Excellent	Above Average	Competent	Unsatisfactory	Not Applicable
ADAPTABILITY: Open to new experiences by trying out different work environments, roles, and tasks.
ANALYSIS/SOLUTION MINDSET: Examines information and data using critical thinking skills and considers different ways to solve a problem.
COLLABORATION: Able to work with a diverse team, encourages using skills of all, and able to manage conflict.
COMMUNICATION: Articulates thoughts and ideas verbally and in writing in a professional manner, uses appropriate content, uses non-verbal communication to make things clear.
DIGITAL FLUENCY: Has a basic understanding of computer, online tools, hardware, and software to find data, information, answer questions, or help solve a problem.
ENTREPRENEURIAL MINDSET: Self-motivated, risk-taker, and seeks new knowledge, skills, ideas, and greater work responsibilities.
EMPATHY: Develops good relationships with people from diverse backgrounds and cultures by being a good listener, asking questions to understand what the other person is feeling, being honest, and mirroring nonverbal communication to build trust.
RESILIENCE: Sets priorities and goals, anticipates possible consequences, develops back-up plans, learns from feedback, and believes in personal growth.
SELF-AWARENESS: Knows own skills and strengths, works to improve weaknesses, maintains self-discipline, takes personal responsibility, and attempts to grow professional manner.
SOCIAL/DIVERSITY AWARENESS: Values diversity in the workplace, develops relationships with people of different backgrounds, and seeks out new ideas from others.

Comments & Feedback of Student Self-Evaluation:

Describe any area(s) and/or skill(s) that show great promise or need improvement.

STUDENT AUTHORIZATION

As a Work Experience student, I understand and approve that my Work Experience Instructor/Coordinator will be providing information about my Work Experience educational activities and enrollment to my Site Supervisor and my Site Supervisor will be providing information to my Work Experience Instructor/Coordinator concerning my educational job-related objectives and records.

Signature *

Clear

Please use your computer mouse cursor or finger on a tablet to physically sign your name as you would for a wet signature.

Date Time *

MM / DD / YYYY

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