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 OverviewApprenticeship AgreementOJT Hours Log