Lari LaBello (309) 999-4651 Downtown Peoria Campus 201 S. W. Adams Street Peoria, IL 61635-0001

Student (Legal) Name (type or print) ______________________________

___________________________

Address _____________________________________City_______________Zip_________ Current Year in School SOPH JUN Gender: Phone #

Social Security # ________ - _______ - __________

Male

Female

(home) ____________________

Date of Birth: ______________________

(cell) __________________

(other) _______________________

Student Email: ____________________________________________________________________ High School:

________________________________

School Phone #

____________________

School Address: ___________________________________________________________________ Counselor Name: _____________________________

Counselor Email: ____________________

Specific health and immunization requirements will be necessary prior to start of class. 2016/17 Options for Work-Based Learning/Dual Credit Health Occupations Program Due 1/31/16 FALL SEMESTER Monday through Friday, 7 a.m.-10 a.m., ICC North Campus Monday through Friday, 7 a.m.-10 a.m., Eureka AC Home Monday through Friday, 7 a.m.-10 a.m., Pekin SPRING SEMESTER Monday through Friday, 7 a.m.-10 a.m., ICC North Campus Monday through Friday, 7 a.m.-10 a.m., Eureka AC Home Monday through Friday, 7 a.m.-10 a.m., Pekin Please indicate your preference of semester and location by selecting ONE of the above. Parent/Guardian: Name: ________________________

Phone # ______________

Email _____________________

Required Signatures: Signing below indicates that student wishes to be considered for the Work-Based Learning/Dual Credit Nursing Assistant Program at ICC. Parent/Guardian signature indicates they believe that their son/daughter has the maturity and ability to be successful in the program, approves of this application, ensures students will be provided suitable transportation, and gives the school permission to release all necessary school records. The student/parent/guardian understands that, in compliance with federal and state privacy laws, ICC may use biographical information for institutional research. We understand that withholding information or giving false information may make a student ineligible for admission to ICC or subject to dismissal.

Student: _____________________________

WBL App.doc/1

Parent/Guardian ____________________________

Date: _____________

Page 2

WBL App.doc/2

WG-Applicationb for WBL with lines - healthoccapp2016a.pdf ...

Page 1 of 2. Lari LaBello (309) 999-4651. Downtown Peoria Campus. 201 S. W. Adams Street. Peoria, IL 61635-0001. WBL App.doc/1. Student (Legal) Name (type or print) ...

66KB Sizes 0 Downloads 185 Views

Recommend Documents

Reflections with lines student version.pdf
Reflections with lines student version.pdf. Reflections with lines student version.pdf. Open. Extract. Open with. Sign In. Main menu.

RoboCop with Folding Lines (by Cepot Patel).pdf
Page 1 of 5. Page 1 of 5. Page 2 of 5. Page 2 of 5. Page 3 of 5. Page 3 of 5. RoboCop with Folding Lines (by Cepot Patel).pdf. RoboCop with Folding Lines (by Cepot Patel).pdf. Open. Extract. Open with. Sign In. Main menu. Displaying RoboCop with Fold

Periodically Nonuniform Coupled Microstrip Lines with ...
two-port impedance matrix of such a symmetrical PNCML structure with the .... [18] L. Zhu, H. Bu, and K. Wu, “Broadband and compact multi-pole microstrip ...

Points and Lines Axis-parallel Lines Hyperplanes ... - Semantic Scholar
segments in the tour (or the path) are axis-parallel. Four Optimization Problems. • Minimum-Link Covering Tour. • Minimum-Link Rectilinear Covering Tour.

Sweeping Lines and Line Segments with a Heap
Sweeping Lines and Line Segments with a Heap. Julien Basch. Leonidas J. Guibas*. Computer Science Department. Stanford University. Stanford, CA 94305. {jbasch,guibas}@cs.stanford.edu. G.D. Ramkumar. Research & Development Division. Hitachi America Lt

Week at a glance with lines PDF.pdf
Page 1 of 1. created by emmastudies.com. WEEK AT A GLANCE. DATE: WEEK NUMBER: /52. MONDAY TUESDAY TO DO. • hello. • hello. • hello. • hello. • hello.

eCounty Lines -
LEADING OFF: Federal Spending Bill Fully Funds PILT, Reauthorizes SRS. There is good news for Colorado counties in the $1.3 trillion federal spending bill Congress passed last week. In addition to funding the federal government through September 30,

Points and Lines Axis-parallel Lines Hyperplanes ... - Semantic Scholar
with constraint, the algorithm fails to find a solution to our counterexample. (Another ..... rankx ¯y(pi ), then initialize the four coordinates ai ,bi ,ci ,di to the index i.

tight lines
bank balance and lack of holidays make me realise that this is not something that can be done on a regular basis. (Steve Long ... In the article Horsey states that he already thought Tasmania had the best Stillwater trout fishery in the world and he

Pairwise Testing for Software Product Lines: Comparison of Two ...
example throughout the paper to illustrate and compare our two approaches for pairwise testing. The FM was added to the FM repository on the SPL. Online ...

Capacitive-Ended Interdigital Coupled Lines for UWB ...
IEEE MICROWAVE AND WIRELESS COMPONENTS LETTERS, VOL. 16, NO. 8, AUGUST 2006. Capacitive-Ended Interdigital Coupled Lines for UWB Bandpass Filters With Improved. Out-of-Band Performances. Sheng Sun, Student Member, IEEE, and Lei Zhu, Senior Member, IE