Supervisor Verification Form

Required for each barbershop training site. Verifies licensed supervisor authority before apprentice placement.

Barbershop Information

Barbershop Name:

Shop Address:

City:

State: Indiana ZIP:

Indiana Shop License #:

License Expiration:

Shop Phone:

Shop Owner Name:

Supervising Barber Information

Supervisor Full Name:

Indiana Barber License #:

License Expiration:

State of Licensure: Indiana

Years Licensed:

Phone:

Email:

Apprentice Assignment

Apprentice Name:

Assignment Start Date:

Expected OJT Hours:

Training Site Compliance Checklist

The following must be verified before apprentice placement at this training site:

☐Active Indiana barbershop license displayed at shop

☐Licensed barber supervisor present during all apprentice training hours

☐Sanitation station properly set up with EPA-registered disinfectant

☐Tool disinfection procedures in place and followed

☐Proper sharps disposal container available

☐Chemical products stored safely and labeled

☐Clean, safe, and well-maintained training environment

☐First aid kit accessible

☐Fire extinguisher accessible and current

☐Shop insurance covers apprentice training activities

Supervisor Confirmation

I confirm that I am a licensed barber in the State of Indiana and will directly supervise the above-named apprentice's on-the-job training at the above-named licensed barbershop. I agree to:

Provide structured hands-on training aligned with the apprenticeship competency rubric
Complete monthly OJT evaluation forms using standardized assessment criteria
Verify and sign OJT hours logs accurately
Maintain a safe, sanitary, and compliant training environment
Cooperate with Program Holder and Sponsor for progress reviews and evaluations
Notify Elevate immediately if shop license or supervisor license status changes

Signatures

Supervising Barber

Print Name: ________________________________

Indiana Barber License #: ________________________________

Signature: ________________________________________________________________

Date: ________________________________

Shop Owner (if different from supervisor)

Print Name: ________________________________

Shop License #: ________________________________

Signature: ________________________________________________________________

Date: ________________________________

Elevate for Humanity (Sponsor Verification)

Verified By: ________________________________

Title: ________________________________

Site Visit Completed: ☐ Yes Date: __________

Approved for Apprentice Placement: ☐ Yes

Signature: ________________________________________________________________

Date: ________________________________

This form must be completed before apprentice placement and maintained in the compliance file.

Elevate for Humanity | RAPIDS ID: 2025-IN-132301 | Indianapolis, Indiana

Barber Rubric Overview Apprenticeship Agreement OJT Hours Log

Training Site Compliance Checklist

The following must be verified before apprentice placement at this training site:

☐Active Indiana barbershop license displayed at shop

☐Licensed barber supervisor present during all apprentice training hours

☐Sanitation station properly set up with EPA-registered disinfectant

☐Tool disinfection procedures in place and followed

☐Proper sharps disposal container available

☐Chemical products stored safely and labeled

☐Clean, safe, and well-maintained training environment

☐First aid kit accessible

☐Fire extinguisher accessible and current

☐Shop insurance covers apprentice training activities

Supervisor Confirmation

I confirm that I am a licensed barber in the State of Indiana and will directly supervise the above-named apprentice's on-the-job training at the above-named licensed barbershop. I agree to:

Provide structured hands-on training aligned with the apprenticeship competency rubric

Complete monthly OJT evaluation forms using standardized assessment criteria

Verify and sign OJT hours logs accurately

Maintain a safe, sanitary, and compliant training environment

Cooperate with Program Holder and Sponsor for progress reviews and evaluations

Notify Elevate immediately if shop license or supervisor license status changes

Signatures

Supervising Barber

Print Name: ________________________________

Indiana Barber License #: ________________________________

Signature: ________________________________________________________________

Date: ________________________________

Shop Owner (if different from supervisor)

Print Name: ________________________________

Shop License #: ________________________________

Signature: ________________________________________________________________

Date: ________________________________

Elevate for Humanity (Sponsor Verification)

Verified By: ________________________________

Title: ________________________________

Site Visit Completed: ☐ Yes Date: __________

Approved for Apprentice Placement: ☐ Yes

Signature: ________________________________________________________________

Date: ________________________________

Supervisor Verification Form

LICENSED BARBER SUPERVISOR VERIFICATION FORM

Barbershop Information

Supervising Barber Information

Apprentice Assignment

Training Site Compliance Checklist

Supervisor Confirmation

Signatures

Supervisor Verification Form

LICENSED BARBER SUPERVISOR VERIFICATION FORM

Barbershop Information

Supervising Barber Information

Apprentice Assignment

Training Site Compliance Checklist

Supervisor Confirmation

Signatures