Mentorship Application 2017-2018
This application is to be completed in it's entirety in order to be processed as an official applicant to the program.

The PMSA Research Mentorship Program provides an opportunity for students to obtain individualized guidance from a professional. Where possible, student participants are paired with a mentor knowledgeable in a similar field of study and/or research interest. Student researchers will be expected to meet all requirements of the course outlined in the course syllabus.

Your submission of this application demonstrates your understanding that this form must be completed accurately and in its entirety by December 1, 2016 by 11:59pm. No submissions after this date will be accepted.

STUDENT INFORMATION
First Name *
Your answer
Last Name *
Your answer
ID Number *
Your answer
STUDENT SELF-ASSESSMENT
I enjoy the process and practice of conducting research. *
I am an independent and inquiring learner. *
I need little direction to complete tasks. *
I am willing to explore various routes to get my own information. *
I am detail-oriented. *
I am self-directed. *
I take initiative to begin work without waiting for the "bell to ring." *
I am punctual. *
I am respectful of others and their time. *
I am a good communicator. *
I am respectful of others and their time. *
I have the ability to interact with a variety of people in many different situations. *
I am well organized. *
I am proactive in keeping up with work in all classes. *
I do not use planned absences as an excuse for not meeting expectations in my classes. *
I am aware of and able to meet deadlines. *
I am aware of the various distractions of Senior year and willing to compensate for them *
I am willing to make some personal sacrifices in order to complete my work. *
ACADEMICS
The counselor will be contacted for current grades.
ATTENDANCE
The counselor will be contacted for your current attendance record.
DISCIPLINE
Have you ever been suspended for any reason while in high school (in-school or out of school) *
Please answer yes or no. If yes, please indicate the reason(s) for the suspension(s):
Your answer
RESEARCH AREAS
Please provide your top 3 areas of research.

Suggestions include, but are not limited to Medical, Engineering, Legal, Criminal Justice, Nursing, etc...

First Choice *
Your answer
Second Choice *
Your answer
Third Choice *
Your answer
RESEARCH CONTACT
Please provide any information regarding research contacts you have already made.
Research Contact(s)
Your answer
RECOMMENDATIONS
Please provide the names of the teachers listed below that will be contacted by the mentorship program facilitator to provide a recommendation for you.
Math Teacher *
Your answer
Science Teacher *
Your answer
English Teacher *
Your answer
Elective Teacher *
Your answer
Research Core Teacher *
Your answer
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