SAM Application Term 2 18-19
Student Name *
Grade Level *
Advisory Teacher *
Email Address *
Have you previously served as a SAM? *
Are you enrolled in the Commitment to Community (C2C) Award program? *
Describe your SAM experience in detail. Who did you SAM for? What duties did you perform? What did you like about the experience? What was difficult for you?
Are you interested in using your SAM hours/experience to count toward this year's exhibition? Yes or No.
Clear selection
Justify how your SAM hours/experience could potentially be valuable enough to qualify as your exhibition experience. For example, what life skills/college connections/real life connections could you gain and then share with the panel. Include any input you may want to share about making the connection between the SAM experience and the exhibition requirement.
What days/blocks are you able to commit to serving as a SAM?
Block 1
Block 2
Block 3
Block 4
Afterschool Office Hours (Mon/Tues/Thurs only)
Wednesday Workshop
What subjects/classes would you be comfortable be a SAM in? (check all that apply)
Why are you the best qualified candidate to be a SAM this year? *
Scenario: A student that you have been asked to work with is being defiant and disrespectful. The teacher is busy instructing the whole class but the student has a worksheet to complete. What would you do? *
Scenario: You are scheduled to SAM with Mr. Hawkins every Monday, Wednesday and Friday during 1st block but you have a big college exam on Friday. It is Wednesday and you would really like to spend the block studying for the exam. What would you do? *
Share any other information or circumstances that will impact your assignment as a SAM:
Once this application is completed, please see Mrs. Holtz in Room 149 (not 1st block), to create your SAM Schedule. Be sure to keep a log of your hours using the forms provided in the Student Union or our website.
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