CAREER & TECHNICAL EDUCATION
STUDENT INFORMATION FOR CHILD GUIDANCE
(FORMALLY CHILD CARE)
Please fill out the following information to be considered for CTE Child Guidance. After completing the form,
save it with your last name and the program area name (Child Guidance). Print one copy for yourself or save a
copy where you can access it later. Follow the directions below to “drop” a copy of the form in the appropriate
program folder. The drop boxes will have a date and time stamped automatically when it is dropped in the box.
*Directions for turning in the forms:
 Login to LMS
 Click on Klein Collins 2012-2013 Community Group
 Click Content tab
 Access Career & Technological Education (CTE) folder
 Drop your completed form in the appropriate drop box
 Blank forms are also in this folder
Please fill in the following information:
Name
Age
Student ID #
Date
Social Security #
Current Grade Level
Date of Birth
Home Phone #
Address
Cell Phone:
Email address:
Relative’s Name
Relative’s Phone #
Do you live with your parents?
Father’s Name
Occupation
Address
Employer
Mother’s Name
Occupation
Address
Employer
Yes
No If not, with whom?
Phone #
Phone #
Approximately how many days of school did you miss this year?
If above 10, please list reason:
How many times were you sent to the office for discipline problems this year?
Why were you sent — for example tardiness?
Please tell your reasons for wanting to participate in the Child Guidance program.
List hobbies, interests, and/or talents you have:
Do you plan to continue your education in this field beyond high school?
Yes
No
What are your plans after high school? (Please check one of the below)
Technical training, preferred school
Military, preferred branch
Two year college, preferred colleges
Four year university, preferred universities
Other, explain
Are you currently employed?
Job Title
If yes, where do you work?
Supervisor’s Name
Phone #
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How long have you been employed here?
List your job responsibilities
Have you taken Child Development?
Yes
No
Have you had experience working with young children?
Yes
No
If so, what kind of experience have you had?
If the Child Guidance class is full, would you consider taking the Instructional Practice in Education and Training course?
Yes
No
List two current teachers as references:
Teacher:
Course:
Teacher:
Course:
The Klein independent School District does not discriminate on the basis of age sex, handicapping conditions, race or national origin in the education
programs or activities which it operates. The Klein Independent School District is an equal opportunity employer.
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