Work-Based Learning Application

** Note for Admins **
1. Update WBL Office email at bottom of the form as necessary. This field is used for routing.
2. If Program Head has not completed the form within 1-week, an escalation task will automatically send it to the WBL Office. Be sure to update email in escalation task if WBL Office email changes.
Please provide the information requested below to apply for Work-Based Learning. Once completed, the form will be sent to the Program Head for additional information before being sent to the Work-Based Learning Office.
Student's Name*

First NameMiddle InitialLast Name
Student's Email*
example@vgcc.edu
PO Box/Street*
City*
State*
Zip*
Home Phone
Cell Phone*
Work Number
Student ID Number*
This your 7-digit student ID number.
Date of Birth*

MonthDayYear
Curriculum Major*
Program Head's Name*

First NameLast Name
Program Head Email*
example@vgcc.edu
Advisor
Projected Graduation Date*

MonthDayYear
Current Employment Information

Please tell us about your current employment status. If you are currently employed, please provide additional information about your current employer.
Employment Status*

I am presently employed in a job that is closely related to my curriculum.I am presently unemployed or employed in a job that is not related to my curriculum, and I am willing to be placed in a career related position.
Employer*
Employer Address*
Work Schedule: (Days)*
(Hours)*
Immediate Supervisor*
Supervisor's Phone*
Optional Resume

If you would like to provide a resume, please include it with your application by attaching it here. Every effort will be made to assist you in finding placement in a career related work experience, but placement is not guaranteed. You, as the student for this class, are the primary person responsible for locating employment which must be approved by your WBL Instructor. The WBL office and faculty in your major will try to assist where possible.
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In rare circumstances, employment through Work-Based Learning may affect the amount of financial assistance students receive from other sources. It is each student's responsibility to check with their Financial Aid resources.

Human Services Students: Demonstrate that field supervisors have no less than the same degree the program awards. It is strongly recommended that field supervisors have no less than one level of degree above the level of degree awarded by the program. Students who intend on becoming certified as substance abuse counselors must meet the requirements laid out by the North Carolina Addictions Specialist Professional Practice Board. For WBL hours to count towards certification with NCASPPB students should have their internship hours recorded and signed by a site supervisor who is a Licensed Clinical Addictions Counselor.
Applicant's Signature*

Clear
Date*

MonthDayYear

Submit Section
IMPORTANT - Program Heads and WBL Office

Don't forget to complete Step 2 in the email once you have pressed Submit!
Should be Empty:

Current Employment Information

* To Be Completed by Program Head *

To be completed by WBL Office

Current Employment Information

*** To Be Completed by Program Head ***

** To be completed by WBL Office **

* To Be Completed by Program Head *

To be completed by WBL Office