LEADERSHIP INTERNSHIP

13 June 2011 – 1 July 2011

Please print and fill out the entire application!

Please make a copy of this form for your own records and mail or drop off the notarized original to:
Project S.O.S, INC
6817 Southpoint Pkwy, Suite 801 Jacksonville, FL 32216 Phone # 904-296-9950 Fax # 904-296-9951
E-mail: Info@projectsos.com

********THE CAMP IS FREE AND ALL ATTENDEES MUST HAVE COMPLETED THE********
9th GRADE PRIOR TO THE INTERNSHIP START DATE

I. STUDENT INFORMATION
Name________________________________________________________________________________________
Last First
Birth Date (Day, Month, and Year)_________________________________________________________________

Sex (Circle One): Male Female

Race/Ethnicity (Circle One):

A. Caucasian
B. African American
C. Hispanic
D. Asian American
E. Native American
F. Other
Home address _________________________________________________________________________________________
Street /Apt. # City State Zip
E-mail ________________________________________________________________________________________
Home phone # __________________________________ Cell phone # __________________________________
Parent / Guardian name(s) _____________________________________________________________________
Parent(s) email ________________________________________________________________________________
Parent(s) work/daytime phone # ____________________ Parent(s) cell phone # _____________________
School attending: _____________________________________ Your grade during the 2011-2012 school year? __________

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II. STUDENT QUESTIONS

• Why do you want to participate in the 2011 Project SOS Leadership Internship?

• What are your long-term goals?

• List your extra-curricular activities/community service:

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

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• What is one issue you see in your community and if you had the opportunity, how would you change it?

• Name 3 strengths and 3 weaknesses that you have.

Strengths:
1.

2.

3.

Weaknesses:
1.

2.

3.

• If you could change one thing about your life, what would it be and how?

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• What is one thing you’d like to change about your school?

• Who is one person that has positively influenced your life and in what way have they influenced you?

• What is one major obstacle you have recently overcome and how?

• What does abstinence mean to you?

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III. REFERENCES
List two references outside of your family members that can attest to your character:
1.____________________________________ Phone Number _____________________________

2. ____________________________________ Phone Number _____________________________

IV. NOTARIZED PARENT SIGNATURE(S) FOR SOS INTERNSHIP APPLICATION

Participant's Signature Date

Participant's Name (Please Print) School Represented

Parent/Guardian's Signature Date

**FREE notary service is available by appointment at the Project SOS office**

CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC

STATE OF_______________
COUNTY OF_____________

This document was acknowledged before me on:

________________________
Date
by_________________________________________
Name
[Notary Seal]
ID Produced__________________________________

__________________________
Signature of Notary Officer

Notary Public for the State of____________

My commission expires_________________

Return Application to:

Project SOS: Leadership Internship

6817 Southpoint Pkwy, Suite 801
Jacksonville, Fl 32216

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