Peer Mentor Program Application (10th

Overview

The Young Emerging Scientist (Y.E.S.) Program is a program of Jewels Academy that provides a hands-on approach to STEM orientation. It aims to increase the young women’s exposure to STEM using a best practice curriculum. The target demographic of the Y.E.S. program are females, minority groups, low-to-medium economic status girls in grades 4th - 9th.

Position Summary

This position requires caring, patience and respect for children. The assistant instructor will encourage the children to be independent and to work collaboratively and model for them appropriate manners and behaviors. The assistant instructor will also instruct children in activities designed to promote social and intellectual growth following the principles of Jewels Academy by performing the following duties specified below.

Student Information

Please complete the following information on the student applicant.

Student First Name *

Student Last Name *

Date of Birth (mm/dd/yyyy) *

Street *

City *

State *

Zip *

Email *

Phone *

Facebook

Twitter

What school will you be attending in the fall? *

What grade will you be entering in the fall? *

T-shirt Size *

Miscellaneous

Do you have a driver's license? *

Yes

No

What is your means of transportation?

Is there any additional information, you would like to tell us?

Parent/Guardian

Please complete the following information on the parent/guardian of the applicant.

Parent First Name *

Parent Last Name *

Parent Phone *

Parent Email

What is the household Income where the you reside? (This information is linked to grant verification purposes)

$30,000 or less

$30,001 to $55,000

$55,001 to $65,000

$65,001 to $85,000

$85,001 to $110,000

$110,001 or more

PHOTOGRAPH CONSENT WAIVER:

I understand that Jewels Academy may photograph my child individually or in a group setting. I understand that photos may be used in brochures, websites, newspapers, presentations, and television spots to further publicize the mission of the organization. I give full consent. *

YES

NO