Name :   Date:

E-mail:

Cell Ph.:              Text Enabled?  Yes     No

College Address :     Facebook?        Yes     No

Home Address :     

Cum GPA:   A copy of your transcript and a resume are also required.

Expected graduation date:     Major:    Minor:

Have you previously worked for a TRiO program?    Yes         No

If yes, where & when? :

Please mark any of the following that you are certified in:       CPR            First Aid       Lifeguard

Are you willing to learn about and drive a 16-passenger van :         Yes     No

Have you ever worked with high school students before?:    Yes     No      

If yes, describe in what capacity:   

Have you ever tutored before?:       Yes       No       If yes, at what level?:

      What subjects would you feel comfortable tutoring?:

Have you ever worked with teenagers in a mentoring capacity before? :      Yes      No

     If yes, in what capacity?:

 Have you ever worked in a residential setting before:   Yes   No

     If yes, describe in what capacity:  

Have you ever been a TRIO program participant?:    Yes     No

     If yes, which program, where, and when?  

List any present employment, including work study, and include your supervisor as a reference below:

List any extracurricular activities or organizations you are involved in (e.g., social or academic):

List any special interests or skills you have that may enhance your work with the APPLE project. 

Please provide contact information for three references: 

         Name:   Title:     Ph:

         Name:   Title:     Ph:

         Name:    Title:      Ph: