Gloucester Summer Internship Program Application
The first step in applying to the Summer Internship Program is filling out this form so that we can get to know a little bit about you and your summer interests. All participants need either proof of citizenship or a green card in order to work.

Accepted participants must:
(1) Accept constructive feedback from the mentor/employer, and ask for supervisor guidance when needed,
(2) Work independently with periodic check-ins but without direct supervision,
(3) Comply with mentor/employer worksite rules and behavioral expectations,
(4) Have a commitment to working hard and learning,
(5) Have a high school or work record free of excessive absences.

If you have any trouble completing this form, please contact LEAP's Gloucester Summer Internship Coordinator, JoAnn Leavitt, at jleavitt@leap4ed.org or 774-270-0119.
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Participant Information
Participant Legal First Name *
(Nombre del participante)
Participant Middle Name
(Segundo nombre del participante)
Participant Legal Last Name *
(Apellido del participante)  
Other Names You Go By (if applicable)
(Otros Nombres)
Participant Birth Date *
(Fecha de nacimiento del participante)
MM
/
DD
/
YYYY
Participant Gender *
(Género del participante)
Participant Sex Assigned at Birth *
(Sexo asignado al nacimiento)
Participant Preferred Pronouns *
(Pronombres preferidos del estudiante)
Participant Ethnicity *
(Etnicidad del participante)
Participant Race *
(Raza del participante)
Participant Country of Birth *
(País de nacimiento del participante)
Month and Year of Arrival in US (if not born in US)
(Mes y año de entrada en USA, si no es nacido en US)
Street Address (include apt # if applicable) *
(Dirección de domicilio, incluyir # de apartamento si es applicable)
City *
(Ciudad)
Zip Code *
(Codigo Postal)
Participant Cell Phone
(Numero de celular del participante)
Participant Home Phone
 (Numero de telefono de casa del participante)
Participant Email (not a gloucesterschools address) *
(Correo electrónico del participante)
Participant Preferred Communication Method *
(Método preferido de comunicación del participante)
Allergies or Medical Problems *
(Alergias or problemas medicás)
Home Information
Parent/Guardian #1 First Name *
(Primer nombre de adulto #1)
Parent/Guardian #1 Last Name *
(Apellido de adulto #1)
Parent/Guardian #1 Relationship to Student *
(Relación al participante)
Parent/Guardian #1 Cell Phone Number
(Número de celular de adulto #1)
Parent/Guardian #1 Home Phone Number
(Número de teléfono de casa)
Parent/Guardian #1 Email
(Correo electrónico de adulto #1)
What is Parent/Guardian #1's preferred communication method? *
(¿Cual es método preferido de comunicación de adulto #1?)
Primary Language Spoken at Home *
(Lenguaje primario hablado en casa)
School Information
School *
(Escuela)
Grade Level *
(Nivel de grado)
Do you have a 504 Plan? *
(¿Tiene un plan 504?)
Do you have an IEP (Individualized Education Plan)? *
(¿Tiene usted un IEP?)
Are you enrolled in an English Learner (EL) Program? *
(¿Está usted inscrito en un programa de (EL) English Learner?)
Guidance Counselor Name
(Nombre de consejero)
Are you first-generation-to-college? (“Yes” means your parents have not graduated from college in the US.) *
Internship Program Information
Areas of Interest *
Please select all that apply. Please write in an interest if none of these match.
Required
Please list your top three areas of interest from above: *
At this time, which of the following types of summer work placement are you interested in (check all that apply). LEAP will be monitoring health recommendations over the coming months in deciding summer work options. *
Required
Please describe any past experience you have had in your fields of interest or any other fields. (Job experience is not required, but this is helpful information.)
How did you hear about this program? Please be specific as to the staff person at your school or the name of the organization you spoke with and the contact. *
HOUSEHOLD AND INCOME INFORMATION
As a grant funded organization, we are sometimes required to report the data requested in this section. Please know that all information will be kept confidential, and receiving this information is crucial to our continued offering of free programs for students on the North Shore. (Como una organización fundada en subsidios, estamos requeridos de reportar los datos solicitados en esta sección. Por favor sepa que toda la información será confidencial, y recibiendo esta información es crucial para continuar la ofrenda de programas gratis para los estudiantes en el North Shore)

Number of Persons in Household *
(Número de personas en el hogar)
Household Income Range *
(Rango de ingresos del hogar)
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This form was created inside of LEAP for Education.