Connecting Activities Job Placement Form

Congratulations on your new job or internship! Please take a few minutes to help out your job coach by filling out this Placement form. For completing this survey you will receive a free gift bag and an invitation to a celebration later this school year!

First Name

Last Name

Email
Please use the personal email address you used when meeting with the job coach (if applicable)

Please select how you identify:

MaleFemaleNonbinaryPrefer not to answer

School Name

Cambridge ExtensionChelsea High SchoolEverett High SchoolMalden High SchoolRevere High SchoolSomerville High SchoolWoburn High SchoolBurlington High SchoolReading High SchoolCityLabCoast Collaborative

Date of Birth (MM/DD/YYYY)

Select how your identify your race/ethnicity

American Indian/ Alaska NativeAsianBlack / African AmericanCape VerdeanHispanicMulti-RacialNative Hawaiian / Other Pacific IslanderWhiteNot specifiedOther

If other, please specify:

Grade

8th9th10th11th12th

Graduation Year

4 characters left.

Employer Placement Name (ex. Target, MGH, Market Basket, etc.) 

Employer/Placement Address

City

State

Please select... AL AK AZ AR AS CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX TT UT VT VA VI WA WV WI WY

Postal Code

Job Title (ex. Camp Counselor, retail associate, intern, etc.)

Start Date

Hourly Pay (ex. 14.50, if unpaid put 0)

Hours per week (ex. 15) 

What type of placement did you get?

Unpaid InternshipPaid InternshipPart-time employmentFull-time employmentVolunteer Opportunity

Is there anything else you would like to share with us about your job coaching experience?