MOY SITE APPLICATION
I. Personal Information
I am applying for the: *
Applicant's Full Name: *
Your answer
I am a: *
If you are a student, please list your year in school:
Your answer
If you are a facutly/staff member, please list your title and University department:
Your answer
Applicant's Email Address: *
Your answer
Applicant's phone number (please include area code): *
Your answer
Is this line a cell, home, or professional number? *
Applicant's home address:
Your answer
II. University/College Information
Full name of university/college: *
Your answer
University/College address: *
Your answer
Check all that apply to your college/university: *
Required
III. Faculty Advisor Information
Required for student applicants.
Name of faculty advisor:
Your answer
Job title:
Your answer
Phone number:
Your answer
Email address:
Your answer
What is the best way for MOY to communicate with your Faculty Advisor?
Your answer
Have you worked with the Faculty Advisor before? Please explain.
Your answer
IV. Applicant References
Required for student applicants.
Full name:
Reference 1
Your answer
Phone number:
Reference 1
Your answer
Email:
Reference 1
Your answer
Relationship to applicant:
Reference 1
Your answer
Full name:
Reference 2
Your answer
Phone number:
Reference 2
Your answer
Email:
Reference 2
Your answer
Relationship to applicant:
Reference 2
Your answer
V. Site Information
Which address would you like the site materials to be sent in the Fall/Spring? (please check one)
How did you learn about Movement of Youth?
Your answer
About how many students have expressed interest in participating in your site? How many students do you anticipate becoming mentors of your site?
Your answer
How will your Movement of Youth site be organized?
What ciites/towns/counties are you recruiting student mentees from?
Your answer
How many student mentees do you hope to accommodate?
Your answer
Where will Saturday Academy sessions be held?
Your answer
VI. Applicant Short Answers
Why are you interested in starting a MOY site at your university? What other activities have you been involved in that may help you lead a MOY site? *
Your answer
Do you foresee any challenges in running a MOY site (such as your class load, sports schedule, work schedule, etc.)? *
Your answer
Are there any additional comments or information you’d like to share with us? *
Your answer
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