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Contact Person #1
Last Name:
First Name:
Phone #
E-Mail
Educ ational Background :
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Contact Person #2
Last Name:
First Name:
Phone #
E-Mail
Educational Background
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Contact Person
#3
Name:
Phone #
E-Mail
Educational Background
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Type of Student:
Summary of Student Opportunity
How many students can your agency accommodate?
How many hours a week could you use a student (10 hour
minimum?)
What days of the week did you want the student to work?:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What times would you need a student?
Do you need your students for one semester or two?
Semester 1
Semester 2
Does the student need a car?
What Medical Tests would be required?
TB
HB
Other:
Will there be home visits?
Will background checks be required?
What type of background check?
Will the agency obtain the background check?
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