PERRY MENTORSHIP PROGRAM
STUDENT APPLICATION

Name: ________________________________________  Grade Level ___________________

Birthdate:_____________________________________   Telephone ____________________

Address ____________________________________________________________________

GPA: _______________________________   Days Absent (Current Year) _______________

E-Mail Address ______________________________________________________________

Parents/Guardians: ___________________________________________________________

Taking mentorship for : (circle one)           1/4 credit      1/2 credit     Non-credit

In what field would you like to complete a mentorship?
(Please be very specific.  Communications is too broad when you are interested in TV journalism or radio broadcasting.  Law is also too general.  It could mean political, judge, etc.  You may list more than one field but rank order of choice.)_______________________________________________________________________

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Why do you wish to complete a mentorship?

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Why are you interested in this particular area? (Please indicate background, if any, you might have in this field.)

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How do you plan to arrive at the work site of the mentor?

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Do you have a job? __________ If so, where and how many hours are you normally scheduled to work?

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Please list school and extra-curricular activities with which you are involved.

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Please list the names of TWO Perry High School teachers to whom you gave reference forms:

                                       Teacher                                                    Subject Area

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Parent/Guardian Signature     ____________________________________________________

Date: _______________________________________________________________________