APPLICATION TO THE LearnServe International FELLOWS PROGRAM 2010/11
Note: Please let your LearnServe advisor at your school know that you are applying to become one of LearnServe International's 2010-11 Fellows. Applications must be received by May 28, 2010.

All fields must be completed!


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Last Name *
First Name *
Email *
Address *
City *
State *
Zip *
Home Phone *
Cell Phone *
If applicable
Year of Birth *
Class of *
Gender *
Required
Ethnicity *
Required
I receive free or reduced-cost lunch at school. *
Required
I receive Medicaid *
Required
Last Name of Parent/ Guardian 1 *
First Name of Parent/ Guardian 1 *
Relationship of Parent/ Guardian 1 to you *
Phone of Parent/ Guardian 1 *
Work Phone of Parent/ Guardian 1 *
Email of Parent/ Guardian 1 *
Last Name of Parent/ Guardian 2
First Name of Parent/ Guardian 2
Relationship of Parent/ Guardian 2 to you
Phone number of Parent/ Guardian 2
Work Phone Number of Parent/ Guardian 2
Email of Parent/ Guardian 2
School Name *
My School is *
Required
Name of Principal *
Name of Nominating Teacher/ LearnServe advisor *
Email of Nominating Teacher/ LearnServe advisor *
Work Experience *
Describe your work experience and home responsibilities, if any.
School and Community Involvement *
Describe how you are involved in your school life, and in any community organization.
Talents, Interests and Hobbies *
Describe your talents, interests and hobbies.
What is an issue you are passionate about and why? *
What is one accomplishment you are proud of and why? *
Travel to meetings *
Meeting locations will change, though all are Metro accessible. Has your parent/guardian seen and approved of the program details, and are you able to attend meetings that begin at 4:30 pm on Thursday afternoons usually at the School Without Walls, in downtown DC near the Foggy Bottom metro station? Please explain.
Commitment *
This program is not just an extracurricular activity, it is an intensive training program that requires a commitment of time and work. This includes meetings 2-3 times per month from September to May, with 1 overnight weekend-retreat, 2 Saturday retreats and service days, the development and implementation of an action project, and weekly on-line discussions. Given your understanding of these requirements, how can you balance this commitment with your other responsibilities?
What do you hope to learn from and what will you be able to offer the LearnServe Fellows Program? *
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