Career Exposure and Life Skills Development Form

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Career Exposure & Life Skills Development Form

Personal Information:

Full Name*

Birthday*

Month

Day

Year

Phone*

Email*

Address*

Emergency Contact Name*

Emergency Contact Number*

Educational Background:

School/Grade Level Completed*

Academic Interests or Subjects of Interest*

Any special needs or learning accommodations*

Career Interests:

Career Fields of Interest (e.g., healthcare, technology, business, trades, etc.)*

Desired Future Career or Academic Goals*

Interests*

Higher Education

Technical Training

Entrepreneurship

Other

Life Skills Goals:

Specific skills you want to develop*

Any prior experience in leadership roles*

Availability:

Date Preferred days/times for participation in workshops, events, and mentoring sessions*

Commitment level*

Part-Time

Full-Time

Parental/Guardian Information (if applicable for minors):

Name and Contact Information of Parent/Guardian*

Permission/Consent for Participation (if under 18)

Yes

No

Health Information:

Medical conditions or allergies that the program coordinators should be aware of*

Any necessary accommodations or support needed during program activities*

Goals for Participation:

What you hope to gain from the program (e.g., job readiness, leadership skills, life skills, career exploration)*

Long-term goals (academic, career, personal development)*

Previous Participation (if applicable):

Prior experience with similar programs or leadership roles (e.g., volunteer work, part-time jobs)*

Mentorship:

Mentorship Preferences:

Interest in being paired with a mentor (if available)

Preferences for mentors based on industry or career field

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