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. By filling this out, you will be entered into a raffle to win one of the 50 power banks or a grand prize of a Samsung tablet! If you have any questions, please reach out to your job coach. Thank you!

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

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?