Worksite Request Form
Employer/Training Agency:
Type of Agency:
Private
Non-Profit
Government
Other
O
ther Type:
Address:
City:
Zip:
Nearest Cross-Streets:
Primary Supervisor:
Phone No:
Alternate Supervisor 1:
Phone No:
Alternate Supervisor 2:
Phone No:
Alternate Supervisor 3:
Phone No:
Please note that one supervisor or alternate is required to be on-site during participant
work hours and participant to supervisor ratio may not exceed 5:1.
Will Youth Require:
TB Test
Background Check
Drivers License
Other:
Is the training site accessible to the physically disabled?
Yes
No
Will you provide the supervision and/or training needed for a disabled youth?
Yes
No
Limited English?
Yes
No
Job Title:
# of Positions Available:
Work Days and Hours Available:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Lunch:
½ hour
1 hour
minutes
List the characteristic(s) that are needed to be successful in this position.
1
4
2
5
3
6
List the job duties and responsibilities that youth will be required to perform. Include tasks that will be part of training.
Comments: