Application Deadline-May 1, 2013

STUDENT PROFILE

Name: ____________________________________________________________________
Last
First
Middle
Name preferred: ________________________________________
Address: ___________________________________________________________________
Street
City
State
Zip Code
Home Telephone: ______________________

Cell Phone: _______________________

Email: _______________________________________
Ethnicity: _________________________

Sex: ______________________

Date of Birth: _______________________

Social Workers Name:_______________________________________________________

Social Workers Email Address: _______________________________________________
Social Workers Phone: ______________________________________________________
Length of Time in Care: _______________________
Do you smoke: Yes

No

Preferred Summer Academy Site:

University of Alabama

Alabama State University

Emergency Contact:
Name: ____________________________________________________________
Address: __________________________________________________
Home #: _________________

Work #: _________________

Cell #: _________________

Email: __________________________________________________

ACADEMIC PROFILE
High School: ________________________________________
GPA: _______

SAT scores (if taken): _____ M _____ V

Grade: ___________

ACT scores (if taken): _______

List all honors and other awards received.

________________________________________________________________________
________________________________________________________________________
List all extracurricular activities (church, school, community) in which you are participating.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

ESSAY
Please attach a two-page, typed, double-spaced essay. Share information about yourself, your
career goals, your interest in the field of social work and why you would like to be a part of
NSEP.

DISCLOSURE
I hereby certify that the information provided in this application is to the best of my knowledge,
true and correct. I have not knowingly withheld any facts or circumstances that would jeopardize
my inclusion in this application process.

SIGNATURE: ________________________________

DATE: _________________