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Media Fellows Application

To apply you must be:

in High School or equivalent GED Program

First Name: *

Last Name: *

Address 1: *

Address 2:

City: *

State: *

Zip: *

Home Phone: *

Cell Phone:

Email: *

Please enter your preferred email address.

Birthday: *

Race (Choose as many that apply): *

Black: African

Black: Caribbean

Black: African-American

Latino

Asian/Pacific Islander

Native American

Middle Eastern

Caucasian

Other

Gender: *

Parent/Guardian First Name: *

Parent/Guardian Last Name: *

Parent/Guardian: Place of Birth: *

Parent/Guardian: Address: *

Parent/Guardian: Home Phone: *

Parent/Guardian: Cell Phone:

Parent/Guardian: Email: *

School Name: *

School Phone: *

School Address: *

Guidance Counselor Name: *

Guidance Counselor Phone: *

Current Grade: *

Do you receive free school lunch?: *

Choose your availability: *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Links to sample work:

One paragraph outlining your filmmaking experience: *

Autobiography: *

Who are you? What makes you, you? What qualities do you bring to the program? Make it personal. We are looking for detailed, honest self-reflection in the response above.

450 word creative writing sample (required): *

450 word essay on “Challenges Facing My Community and Me” : *

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