Mental Health Career Pathways Summer Program Application/Permission Form
Section 1 is to be completed by the child applying to participate. Sections 2 through 5 are to be completed by parent/guardian granting the child permission to participate. It should not take more than 5 minutes for the parent/guardian to complete those sections.

Please FULLY complete forms below. Incomplete applications will not be considered. You will be contacted with further instructions and information at a later date. All high school age students (entering grades 9 through 12 in fall of 2021) are eligible to apply. You may also apply if you are a 2021 high school graduate.

The summer program will run in Van Wert:
July 6th through August 5th
Monday through Thursday (week one runs Tuesday-Thursday due to the July 4-5 holiday)
9am-noon
Location:
Vantage Career Center
818 North Franklin St.
Van Wert, Ohio 45891

Please submit this application form by June 15, 2021 to be considered.

Questions or need more information? Contact:
Lucy Flowers, Director of School Based Programs
Prevention Awareness Support Services (PASS)
lflowers@passaah.org
419-549-8530 extension 3
Email *
Applicants age: *
Fall 2021 grade level *
Optional-Preferred pronouns (he/she/they/neo pronouns etc.)
Applicant's full name *
School district you attend *
County of residence *
Full home address (include city, state and zip) *
Phone number *
What is the best way to contact you if you are selected? *
Cell phone carrier (e.g. verizon, at&t, sprint, t-mobile etc ) *
T-shirt Size (Adult Cotton) *
Why are you interested in pursuing this opportunity and/or a degree/career in mental health? *
What makes you stand out as a candidate to be selected for this program? *
Do you have any plans for summer vacation or other obligations that will hinder your daily attendance? If yes, please explain. Dates/times for the summer program are listed above in the form instructions. *
PASS strives to create an inclusive, welcoming environment for all consumers. To that extent, we are considering including an outing the last day of the program that involves outside activities such as swimming (possibly at Camp Clay). Would you feel comfortable in a setting that involves these activities? (this answer will remain anonymous) *
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