Student Application

"*" indicates required fields

Contact Information

Full Name*

First Last

Age*

Please enter a number from 12 to 19.

Email*

Phone (Day)

Phone (Night)

Mailing Address*

Street Address City State ZIP Code

County of Residence*

Application Details

Current Overall Grade Point Average (GPA)

Please enter a number from 0 to 5.

Name & Phone Number of Guidance Counselor

What is your T-shirt Size?

Have you ever been accused/convicted of a felony?*

Yes

Do you have Experience in Volunteer Settings?*

Yes

Though not required for program admission, please describe your Experience(s) in Volunteer Settings.

Though not required for program admission, please describe any experience(s) you have in Disaster Preparedness and Relief Settings.

Though not required for program admission, please describe any experience(s) you have in Leadership Development programs.

How does this opportunity fit within your current life/school/extracurricular schedule?

What have you enjoyed most about previous Volunteer Experience(s)?

Why are you interested in MyPI?

How did you hear about MyPI?

What are your hobbies and interests?

What would you like to gain from an experience as a MyPI participant?

Would you travel to an adjacent city/county for your program?*

Typically, MyPI participants join a cohort group in the communities where they reside. However, in the event that we are not able to fill a cohort of 18 to 24 teens from your area, there may be opportunities for you to join a cohort in an adjacent community.

Yes

What would you like to know about MyPI?

Thank you for your interest in MyPI. If you have any questions/comments, please feel free to contact Angie Smith, MyPI Pennsylvania, State Program Manager at (570) 832-2804 or at axs1397@psu.edu.

Applications will be evaluated by the MyPI Administration. Official notification of selection will take place as soon as possible after reviewing and verifying information. Early submission of MyPI Participant Application and Information Form is strongly encouraged.

Name

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