Shodor: Mentor Center Application

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First Name

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Last Name

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Email

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How did you hear about this program?

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When are you available to work?

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Street

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City

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State

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Zip Code

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Phone Number

Street

City

State

Zip Code

Phone Number

Sex

Ethnicity

Date of Birth

Place of Birth

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Are you a U.S. Citizen?

If you're not a U.S. citizen, state your country, citizenship, and type of visa you hold.

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Applicant skill set employable at Shodor

Graphics	Programming	Web Design
System Administration	Education	Mathematics
Science

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Name of School

Street

City

State

Zip Code

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Year in school

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Teacher/Academic Reference Name

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Teacher/Academic Reference Phone Number

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What are your future plans for study or work?(Please indicate by selecting from the following)

Enter the workforce

Attend Community College

Attend four year college or university to pursue degree in science, math, engineering, or technology

Attend four year college or university to pursue degree in another field

Attend graduate school to pursue advanced degree in science, math, engineering, or technology

Attend graduate school to pursue advanced degree in another field.

Subject areas that you have studied (check all that apply)

Environmental Science	Chemistry	Meteorology
Pre-algebra	Pre-calculus	Statistics
Computer Science	Earth Science/Geology	Biology
Physics	Marine Biology	Algebra
Calculus	Algebra II/Trig	Medicine/Biomedical Sciences
Forensic Science

Subject areas that you would like to study (check all that apply)

Environmental Science	Chemistry	Meteorology
Pre-algebra	Pre-calculus	Statistics
Computer Science	Earth Science/Geology	Biology
Physics	Marine Biology	Algebra
Calculus	Algebra II/Trig	Medicine/Biomedical Sciences
Forensic Science

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List the science and mathematics courses/experiences which you have most enjoyed.

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Describe how you've spent your last two summers.

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Write a short essay (2-3 paragraphs) describing your interest in science and your career goals. Include a discussion of any research or science fair projects in which you have participated as a student.

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How can this program benefit you?

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How can you benefit this program?

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I certify that all of the above statements are true.

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