Fillable Dairy Herd Management Program On-Farm Placement / Emergency (Lakeshore Technical College)

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Dairy Herd Management Program On-Farm Placement / Emergency (Lakeshore Technical College)

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Please send to: Admissions
Dairy Herd Management Program
Lakeshore Technical College
1290 North Avenue
On-Farm Placement / Emergency
Cleveland WI 53015-1414
Fax: 920-693-3561
Dairy Herd Management on-farm internship placement requires additional student information. The following information helps
ensure successful placement. In meeting the needs of all program students and cooperating (internship) farms, the program
attempts to accommodate your request. However, not all requests can be met.
Today's Date SS#
Name Email Address
Address City State Zip
Home Phone ( ) Cell Phone ( ) Best Time to Call
Planned Entry Date into Program Fax Phone ( )
1.
F
M
a
l
e
F
F
ema
l
e
Age_____
F
Si
ng
l
e
F
M
arr
i
e
d
# Children______
2.
What is your dairy background? Check all that apply.
F
Born and raised on a dairy farm
F
Two to three summers working on a dairy farm
F
Have had high school agriculture classes
F
Worked on farm (other than parents) during high school
F
Have had post-high school agriculture classes
F
Have had posthigh college classes
College attended________________ Location__________ College Degree Obtained___________________________
3.
D
o you nee
d
to
b
e p
l
ace
d
on a
f
arm
?
F
Y
es
F
o
4. If you do not need to be placed on a farm, please check the appropriate option below, provide employment information,
and skip to Question 11
and skip to Question 11
.
F
I will be living at home
F
I have already made my farm arrangements
If arrangements have been made, provide contact information of where you will work while attending LTC..
Name Phone
Address City State WI Zip
5. When would you like to start work at your cooperating (internship) farm?
F
As soon as possible
F
One to two weeks before school starts
F
Right before school starts
6. If you need to be placed on a farm, check which situation you would prefer.
Herd Size
F
60-100
F
100-250
F
250+
F
No preference to size
Type of Setup
F
Stall barn/pipeline
F
Free-stall parlor
F
Grazing / swing parlor
F
Flat-barn parlor
F
No preference to set-up
7. Breed & Herd of Choice. For each, check which situation you would prefer.
F
Holstein
F
Colored Breed
F
Registered
F
Grade
F
No Preference
F
No Preference
8.
9.
Which of the following situations would you prefer?
F
Live at the farm you are cooperating with.
Which farm situation would you prefer?
F
Work one to two weekends each month.
F
Live in separate housing of your choice.
(C
ommon w
ith
par
l
or se
t
ups
)
F
Work most weekends/work as much as possible.
10. Which farmer would you prefer to live with?
F
F
Young couple with small children
Y
oung coup
l
e w
ith
sma
ll
c
hild
ren
F
No Preference
F
F
Middle aged couple with older children
Middl
e-age
d
coup
l
e w
ith
o
ld
er c
hild
ren
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
____________________________________________ ______________________ ____________________
11.
12.
13.
14.
15.
16.
17.
18.
19
19.
20.
21.
22.
23.
List any health problems you may have._______________________________________________________________
F
Smoker
F
Nonsmoker
When was your last Tetanus immunization?______________________________________
Note: It is highly recommended that you are current with both your Tetanus/Diptheria and Tuberculin Skin Tests. Call your Public Health Nurse for appointment.
Other than dairy cattle, list your interests, and related achievements, associations, memberships, etc.
Rank these areas of interest; with #1 being first.
_
_______
_
Record Keeping
_
_______
_
Cow Families/Breeding
_
_______
_
Feeding/Rations
_
_______
_
Showing Cattle
_
_______
_
Veterinary/Herd Health
_
_______
_
Field Work
_
_______
_
Calf Care
_
_______
_
Crops/Soils
_
_______
_
Milking
Previous Employment:
Dates:_____________________ Name__________________________________Location_______________________
Dates:_____________________ Name__________________________________Location_______________________
Dates:_____________________ Name__________________________________Location_______________________
Is there anything you want to add as it pertains to the on-farm placement?
Have you ever been convicted of a crime?_________________________________
If "yes," state the 1) nature of the offense, 2) when, 3) where, and the 4) disposition.
Do you hold a valid driver's license? _____________________________________
Student Emergency Information
K M di l C diti ( )
Known Medical Condition(s)________________________________________________________________________
_
Medications Presently Taken________________________________________________________________________
Allergies_________________________________________________________________________________________
In Case of an Emergency, Please Notify:
Circle Parent / Spouse / Other Home Phone Cell or Work Phone
Family Physician_______________________________ Office Phone_____________________________________
Local Hospital Preference________________________
F
I have no local hospital preference.
Consent for Release of Confidential Information
I, ______________________________________________________, give my permission to Lakeshore Technical College
staff, its employees and agents, to release 1) the above information or a copy of this form, 2) my attendance and grade
information, and 3) my Student Emergency information, as part of and for the purpose of facilitating the on-farm placement
process, to prospective cooperating farmers. This release expires two (2) years from the date of my signature.
Signature________________________________________ Date___________________________________________
If a minor, please have a parent/guardian sign.
Parent/Guardian Signature_____________________________
_
Date___________________________________________
If you have questions, please contact Don Geiger, Counselor, 1.888.468.6582, Extension 1109.
Admissions Please forward one copy of completed form to Sheryl Nehls Program Instructor
Admissions
,
Please for
w
ard one cop
y
of completed form to Sher
y
l Nehls
,
Program Instr
u
ctor
and forward one copy to the College Health Nurse Revised: 2/2004
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Dairy Herd Management Program On-Farm Placement Emergency (Lakeshore Technical College)

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Completed 9 October 2020

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