Mosaic 2018 Summer Journalism Workshop  

June 11 - 22 

Student application
Name: ____________________________________________________________________

Birthdate: ______________________________

Email: _________________________________ Student cell phone: ________________

Parent name(s): _____________________________________________________________

Parent phone: _____________________ Parent email: _____________________________

Home address: Street: ________________________________________________________

City, State ZipCode: _________________________________________________________

School: __________________________________________ Current grade level: _________

Gender: ___________ Ethnicity: _______________________________________________

1) In 100-300 words, please explain why you are interested in participating in Mosaic (attach
additional sheet if needed). Are you interested mainly in reporting or photography ?

2) Does your school offer (circle those that apply) Journalism class Journalism club Video class
Yearbook class Photography class Multimedia class Web design class Other media (explain)

3) Which of the above classes have you participated in? (experience is not necessary)
4) What are your interests? Circle all that apply
Writing Reporting Audio/Video Reporting Web design and management Photography
Making a difference in my community Learning about particular issues Meeting new people
Having my views represented in the media Learning other skills (list):

5) Please describe three stories or photo/video essays you would like to produce, or issues you
would like to explore. Please be as specific as possible. Why are you interested in these
subjects? Attach a separate paper if needed.

6) What are your current educational or career goals?

7) Is there anything that we need to consider to enable you to participate? Other commitments
such as job or family obligations, or transportation needs?

8) Please attach a sample of your work -- a news story if you’ve taken journalism, a class
assignment or personal or independent writing, or photographs (digital file is fine).

9) Please list the name, cell phone number and email address of someone at your school who
could provide a reference for you.

10) Other comments or ideas?

Scan and email this application ​by April 8 ​to: ​snoguchinews@gmail.com