OCSP 2013-2014 Ambassadors Application


Applicant Information

*Note: Applicants MUST mail in the most recent copy of their report card. A GPA of at least 2.5 is required.

Registration Options

  • Fax: 812-856-0445
  • Mail: Office of Community & School Partnerships
    1900 East 10th Street
    Eigenmann Hall Room 617
    Bloomington, IN 47406
    Application: 2013 Ambassador
  • Register Online
    For more information, please contact Kim Morris-Newson kmorrisn@indiana.edu 812-856-6003




Tell us about yourself:

First Name of applicant: Last Name:
Age: Gender:
Local Address:
Class Standing: Major:
Phone number: Cell Phone:
E-mail: GPA:

T-Shirt Size:

Small
Medium
Large
X-Large
XX-Large
XXX-Large

Check which program(s) or organization(s) you belong:

21st Century Scholars
Black Cultural Center
FASE/OMSLD
Asian Cultural Center
Hudson & Holland
Latino Cultural Center
Groups
First Nation Cultural Center
Belongs to None Listed







Other Organizations: Enter N/A if it does not apply.

Please provide two references:

1) Name:
E-mail Address: Phone Number:


Please show class schedule, including class times:

Monday

Tuesday

Wednesday

Thursday

Friday

What middle school did you attend? (Name, city, state):

Do you have public speaking experience? If so, please explain:

Have you had any experience working with elementary school children?:


Which program(s) would you like to apply for?

College Kids - 1-day program for 4th--6th graders
College Life Tour - visit middle schools in Indiana
Campus Tours - panel discussions & campus tours
Spring Shadow - mentor high school students
       Required: Please Select Session(s) and Mentors for Spring Shadow
       Session 1 March 30 - April 1        Session 2 April 6 - 8
       Lead Mentors          Day Mentors
      

* Lead Mentors will meet, greet and stay with Mentees in the dorm. The Mentors and Students will stay all together in the dorm for two night. Lead Mentors will go to dinner, bowling and attend a Tuesday morning presentation.

* Day Mentors will meet and greet Mentees on Sunday and pick up their Mentees on Monday at 8:00am from their dorm, take the Mentees to classes and bring them to dinner at 5:00pm. Day Mentors may stay for evening activities if your schedule allows.

Have you ever been convictied of a crime? (yes/no):

If yes, choose one of the following:
misdemeanor felony


Emergency Contact Information

First Name: Last Name:
Relationship: Email:
Home/Cell Phone:


Please read and initial the following statement:
I certify that all information given is true. I understand that any false statement made herein or ommission of convictions or current criminal charges is sufficient reason for rejection of this application.

To agree to the terms above, place your initials here:
Date: