MassCOSH

Massachusetts Coalition for Occupational Safety and Health

42 Charles Street Dorchester, MA 02122

(617) 825-SAFE (617) 822-3718(fax) www.masscosh.org

Application for MassCOSH Teens Lead @ Work

DUE: Friday, May 23rd , before 5PM

Personal Information Date_______________

Last Name: First Name:

Address:

City: State: Zip Code:

Home Phone: Cell Phone:

School Information (If you are not in school, please explain why?)

Name:

Address:

City: State: Zip Code:

Work/Volunteer Experience

Company Name:

Job Title:

Start Date (MM/DD/YR): End Date (MM/DD/YR):

Reason For Leaving:

Company Name:

Job Title:

Start Date (MM/DD/YR): End Date (MM/DD/YR):

Reason For Leaving:

How did you hear about Teens Lead at Work? What do you know about the work we do? ______________________________________________________________________________

How have you been a leader in your community (school, home, friends, volunteering, etc..)? Explain.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Why do you want to become a Peer Leader for MassCOSH Teens Lead @ Work? What skills do you hope to walk away with?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are some problems facing teens in the workplace? What should be done about them?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please also answer the following question and be creative (essay, picture, or poem, etc…) (attach your answer to the application): There are several problems teens face in the workplace. Pick the one you feel is the biggest problem in the workplace for young adults. Explain why you chose the problem, what we can do to solve it, and how you would create a movement around the issue.

Employment Agreement

The information I have provided above is accurate and true. If for any reason any of the information that I provided MassCOSH with happens to change I will be sure to contact the Hiring Manager.

Signature: Date: