Youth Initiative Mentoring Academies (YIMA) - Application Form
Last Name:
 First Name:
 Middle:
 Phone: (Day)
Phone: (Evening)
Address:
City:
 State:
 Zip:
Age: Date of Birth: Gender:
Race/Ethnicity:

PARENT’S INFORMATION (if under 18)
Parents Last Name: First:
Middle Init: Age:
Address: City: State: Zip:
Phone (day):
 Phone (evening):

EDUCATION
Years complete
Elementary
(select one) High School
  Post High School
School you are currently attending:
 Grade:
What is your approximate overall grade average in:
Mathematics Reading Science Citizenship
HEALTH
1. Do you have any current health concerns/problems which would negatively affect your ability to:
A. Participate in the classroom portion of the Academy (e.g., eyesight, problems with sitting,standing, walking, hearing, speaking?)
If yes, explain

B. Fly in an aircraft (e.g., asthma, motion sickness, fear of heights, etc.?)
If yes, explain
2. Do you use or have a history of using:
Drugs Alcohol Marijuana Cocaine Amphetamines Other?
BRIEF AUTOBIOGRAPHY
Who are you? What are your strengths? What are your limitations? Why do you want to enroll in the YIAA program?
REFERENCES
List the names of three (3) adults (other than relatives) who will write a letter of reference for you. Fill out the top portion of the attached letter, give each of them a copy and ask them to return the completed letter to the address on the letter.
Name:
 Title/Occupation: Phone:
Name:
 Title/Occupation: Phone:
Name:
 Title/Occupation: Phone:
Please download and print out this file and give to your listed references to complete. [Download File]
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