Club 21 Scholars 2022-2023 Application : What We Do : Club 21 Learning and Resource Center

Club 21 Scholars Program Application

Full name (first and last)

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Please do NOT enter an email address associated with your school.

Phone number

Address

Please list any languages other than English that you speak.

(Optional) Please write the race that you identify with.

What school will you attend for the 2022-2023 school year?

You must attend a public school to be eligible to apply for this program.

What grade will you be in for the 2022-2023 school year?

Only 11th and 12th graders are eligible to apply for this program.

How did you hear about this program?

Please list the name, position, and contact information (phone number and/or email) of one reference.

Have you ever worked or volunteered with someone with a disability? If so, please describe your experience.

Prior experience working with individuals with disabilities is NOT required for this program.

Why would you like to be a part of this program? What would you like to get out of it?

Describe your experience being part of a team.

This may include sports teams, school projects, work experience, etc.

Please describe your prior volunteer or work experience and if you have any experience working with children here.

Prior volunteer or work experience is NOT required for this program.

What do you believe is your greatest strength?

Describe a challenge that you have or are working to overcome.

If you have been fully vaccinated for Covid 19, please upload a picture or scan of your vaccination card here:

Full vaccination is two doses of Pfizer or Moderna, or one dose of Johnson and Johnson.

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If you have not been vaccinated against Covid-19, please check the box below to acknowledge that you will need to present a negative PCR Covid-19 test result at least one day before you volunteer at a Club 21 event. The test will have to be taken within three days of the day you volunteer.

I acknowledge the statement above.