Jefferson County High School
115 W. Dumplin Valley Road
Dandridge, TN 37725
(865) 397-7384

STUDENT’S NAME _______________________GRADE_______DATE__________

In order to participate in Job Shadowing with JCHS, the job site and employee must be approved and
you must have satisfactory grades and attendance.

1)  Have you job shadowed during this school year?                        YES     or         NO
            If you circled YES, you will not be allowed to job shadow again this school year.

2)      Career Area in which you are interested in Job Shadowing: __________________

3)      Do you already have a job shadowing site?                               YES     or         NO

If you circled YES, please list where you will be and with whom you will be:     
            Job Site:     __________________________________________
            Site Host:   __________________________________________
            Phone:        __________________________________________
4)      Do you need assistance to help you with a job site and employer?  YES   or   NO
Your grades, attendance, and potential job site will be checked.  You will be notified within a week
about the status of your application.

                                                                   To be completed by the Job Shadowing Coordinator:

_____Your Job Shadowing Application has been approved.  Please note the job site, date, and time for which your Job
Shadowing experience was approved:

                                        Job Site:                 _________________________________________
                                        Site Host:               _________________________________________
                                        Phone:                    _________________________________________
                                        Date:                       _________________     Time:    _______________
_____Your Job Shadowing Application has not been approved due to the following reason(s):
                        ___Unsatisfactory Attendance                         ___Other
                        ___Unsatisfactory Grades                                                 ____________________________              
                ___Inappropriate job site                                                   ____________________________
___Attendance Satisfactory                                    ___Grades Satisfactory
___Ms. Rimmer Notified                                        ___Teachers Notified
___Job Site Approved                                          
___#1 Job Shadow Application     
___#2 Contract Signed by Parent/Student Liability
___#3 Form Signed by Parent/Student

                                                             _______________________  __________                                                                                          
                                                          Job Shadowing Coordinator     Date



Job shadowing is an opportunity for you to spend a day in a work-place learning what employees really 
do on the job in a career field that you are considering pursuing after high school, technical school, or 
college graduation.
In order to participate in the job shadowing experience, fill out an application form and return it to Mrs. 
Potter in the Career Tech office.  You will be notified if your application has been approved.  You may 
choose your own site and host for approval, or Mrs. Potter will assist you with an appropriate placement.
When your paper work and signatures have been submitted to Mrs. Potter then your Job Shadowing Day 
will not count as an absence and you will not lose your two points of “perfect attendance.”
Your Responsibilities As A Student “Shadow” Include:
·        Being supervised by a work-place host at all times during your job shadowing experience
·        Observing all workplace and school safety and security procedures
·        Reading all orientation materials prior to attending the shadowing experience
·        Dressing appropriately for your job shadowing experience
·        Interacting with your work-place host respectfully, courteously, and enthusiastically
·        Learning about the work-place host’s job, industry, and the working world
·        Asking questions about the host’s job and career
·        Writing a thank-you letter to your host
·        Complete the Follow Up Report and return to Mrs. Potter
I agree to abide by the Job Shadowing Requirements and Responsibilities.
______________________________________    ________________________________
Student                                                                     Parent

Parental Permission Form and Release from Liability
Code of Conduct and Transportation Agreement
Mentoring, Job Shadowing, and Internships
Jefferson County High School
I/we ____________________________and ____________________________________, the lawful parent(s)
or  guardian(s) of:
Jefferson County High School (JCHS) Student _______________________________________________________
Hereby give permission for the above mentioned student to participate in Mentoring, Job Shadowing, and Internship Program
known as Work-Based Learning conducted through one or more of his or her courses in the Jefferson County School
System.  Understand that I the parent(s) or guardian(s) of the above mentioned student will be required to provide reliable
transportation enabling the student to drive to the work-based learning site each school day.  I am granting permission for the
above mentioned student to leave campus at the time designated by the teacher or Work-Based Learning Coordinator.

Release from Liability
We, the lawful parent(s) or guardian(s) of the above mentioned student, and I the above mentioned student, hereby release
Jefferson County, the Jefferson County Board of School Commissioners, Jefferson County Director of Schools, all
employees of the Jefferson County School System, including teachers, the Work-Based Learning Coordinator, the Career and
Technical Counselor (CTE) of JCHS, and all participants in the Work-Based Learning Program from liability for any and all
injuries, death, property damage, or other claims, including claims based on negligent or other inappropriate, arising from or
occurring during participation in Mentoring, Job Shadowing, or Internship Study known as Work-Based Learning, whether
such claim arises at school or in the work place.  I further understand that Mentoring, Job Shadowing and Internship study
involves the student working for no pay or monetary compensation at a job site in the private sector.  The school setting is
controlled by the school system.  The private employer is not.  Mentoring, Job Shadowing, and Internship Study will subject
the student to an adult work environment including the experiences and hazards normally found in the type of business that
works with the student and particularly found in the employers work place.

Code of Conduct Acknowledgment
The lawful parent(s) or guardian(s) and I the above mentioned student, hereby acknowledge that I/we understand and have
received a copy of the rules of student conduct enacted by the Jefferson County Board of School Commissioners listing
school rules and consequences for violations under assertive discipline, the safety rules for participation in Work-Based
Learning, and any and all rules of conduct given by any teacher or Work-Based Learning Coordinator and agree to abide by
them under penalties described by and enforced by the Jefferson County School System and Tennessee Department of

Transportation Agreement

We the lawful parent(s) or guardian(s) of the above mentioned student, and I the above mentioned student, hereby agree to
provide reliable transportation the work-based job site on a daily basis or as assigned by the teacher, work-based learning
coordinator, school counselor or school administrator.  I further agree to abide by all state vehicle operation, registration, and
insurance laws and school parking regulations.

Date(s) of student participation:       _____________  _____________  _____________  _________________________
                                                                Month                    Day                         Year                        Time

__________________________   _____________
Student                                                  Date

__________________________   __________________________________________              ________________
Parent/Guardian                                   Parent/Guardian                                                                                   Date
Emergency Phone Numbers:
Submit the name and phone number of at least two persons that could be contacted in case of emergency.




Name of Student _____________________________
Date ____________________________________
Number of hours spent during Job Shadowing experience________________________
Location of Job Shadowing Experience ______________________________________
Name of Employer/Mentor________________________________________________
Describe what you did or observed during your Job Shadowing experience.
What type of education is required for the job? _________________________________
If college is required, what major should be pursued? ____________________________
What does your employer like best about his/her job? ____________________________
What does your employer see as disadvantages of his/her job? _____________________
Student’s Signature___________________
Employer’s Signature _________________
Please return this form to Mrs. Potter the school day after your experience. If this form is not
received on the school day after your experience, your Job Shadowing Day will count as an unexcused