IMAGINE - Membership Interest Application
Advisory Teacher
Your answer
Grade
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PERSONAL INFORMATION (Applicant) *
First Name
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Middle Initial
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Last Name
Your answer
*
Date of Birth (DOB) - Month / Day / Year
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PERSONAL INFORMATION (Parent/Guardian) *
First Name
Your answer
Middle Initial
Your answer
*
Last Name
Your answer
EMERGENCY CONTACT *
First Name
Your answer
Middle Initial
Your answer
*
Last Name
Your answer
*
Home Phone
Your answer
*
Parent/Guardian’s Work Phone
Your answer
*
Parent/Guardian’s Cell Phone
Your answer
Permanent Address *
Address 1
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Address 2
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*
City
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*
State
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*
Zip Code
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*
Parent/Guardian’s Email Address
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*
Applicant’s Email Address
Your answer
Do you have transportation to IMAGINE events? *
Applicant Response
Required
Do you have internet access? *
Applicant Response
Required
If YES, what type of device?
Applicant Response
Your answer
Can you use your device during IMAGINE meetings? *
Applicant Response
Required
What size T-shirt do you wear in adult sizes? *
Applicant Response
Required
In your own words, describe the reason you would like to become a member of IMAGINE WELL. (Applicant & Guardian Response) *
Applicant Response
Your answer
*
Parent/Guardian Response
Your answer
ACADEMIC BACKGROUND *
List any academic honors received in the last two (2) years. Please include when and where.
Your answer
ACADEMIC BACKGROUND (cont’d) *
List any activities that have allowed you to serve as a role model for other people at your school or in your community:
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*
What talents do you possess?
Your answer
*
List any community based programs you are part of?
Your answer
Please list one program you would like IMAGINE to implement. Describe the target audience and purpose. (Applicant & Parent/Guardian Response) *
Applicant Response
Your answer
*
Parent/Guardian Response
Your answer
PERSONAL ASSESSMENT When placed in a tense situation... *
1. How do you exercise good manners?
Your answer
*
2. How do you handle conflict?
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*
3. How do you strive to create a supportive environment?
Your answer
Signature of Parent/Guardian *
Your answer
Signature of Applicant *
Your answer
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