2. This form is for use by organizations and businesses who would like to participate as a work site for the CareerChoice Work Experience Program.   As a result, we ask that you please provide information on your organization and/or business.

   CareerChoice assists Charles City youth ages 14 to 24 in choosing a career, preparing for the career, and becoming a valuable and self-reliant member of the community. CareerChoice tailors its services to meet the needs and goals of each youth and works to create opportunities for their future success.
   

   
   

4. Please provide the name of your organization, business, or department.*
6. Name*
7. Email Address*
9. Address*
11. City*
12. State
13. Zip Code*
15. Phone Number*
16. Fax Number
18. Please indicate the type of organization/business.*

    1. Non-Profit Organization
    2. For-Profit Organization
    3. Charles City County Government
    4. Local Government Agency
19. Please indicate the preferred age(s) of program participants.*

    1. 14 - 16 years
    2. 16 - 18 years
    3. 18 - 24 years
    4. Any
21. Please provide additional information on the services provided by your organization/business.*
23. Please provide information on the type of work experience to be potentially provided by your organization/business.*
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field