PFE Program Student Application
Person Submitting Form *
Student Information
Student First Name *
Your answer
Student Last Name *
Your answer
Student Email *
The email address entered here will receive the approval status from Visit Reflections submitted and all other communications from your school's program.
Your answer
Student Mailing Address *
Your answer
City *
Your answer
State *
ZipCode *
Your answer
Student Phone Number
Your answer
Parent Phone Number *
Your answer
What is your preferred method of contact during non-school hours? *
Senior Mentor Information
You and your parents may have already chosen a Senior Mentor. Please tell us a little bit about them.
Senior Mentor's Name
Your answer
Senior Mentor's Address
Your answer
Senior Mentor's Phone Number
Your answer
Senior Mentor's Email
Your answer
How do you and your family know this person?
Your answer
What companionship and/or chore activities will you perform during your visits with this person?
Your answer
Please tell us about any previous experience you have had in PFE.
Be sure to include school name and year(s).
Your answer
Why do you want to be a part of PFE? *
Your answer
PFE Program Commitment Pledge
Please check all the boxes to indicate you agree to and will uphold your commitment to the PFE program.
I understand and agree to the following: *
Required
Student Acknowledgement *
By providing an electronic signature below, my parents and I understand and agree to the requirements of the PFE scholarship program. I also understand that PFE program slots are limited and acceptance is not guaranteed. Final determination may be made following an interview with my school's Program Administrator. (Please type your name below)
Your answer
School Information
School Name *
Grade Level *
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