2012-2013 Water Resources Institute

High School Internship Program Application

Please submit the following items along with your completed application:

- A Copy of your Current Grades & Transcript with your most recent CSTs scores

- A Copy of your Attendance Report and Current Class Schedule

- Completed School Record Release Form

I. Personal Information

Full Name: / Date:
Last / First / M.I.
Address:
Number + Street/ P.O Box Number / Apartment/Unit #
City / State / ZIP Code
Cell Phone: / ( ) / E-mail Address: /
Home Phone: / ( ) / Date of Birth:
Grade: 8th 9th 10th 11th 12th Gender: Male Female
Overall Grade Point Average (GPA):
4.00 or above 3.99- 3.50 3.49- 3.00 2.99- 2.00 1.99 or lower Not Available
Indicate your GPA Scale: 4 point 5 point Other, specify:
Current Class Ranking: Student I.D. #:
U.S. Citizen:
Not a U.S. Citizen: / Permanent Resident Card #: Exp. Date:
Applied for Citizenship (must provide copy of the request)

II. Ethnicity

Native American Caucasian Hispanic or Latino Asian African American
Pacific Islander or Native Hawaiian Alaskan Native Other, specify:

III. Current High School Information

High School: / Phone: Fax:
Number and Street: City: State: Zip Code:
Counselor’s Name: / / Counselor’s Phone Number: / / Counselor’s Email: /

IV. Current Course Work

Math Class: Algebra I Geometry Algebra II Pre-Cal Other:
Science Class: Anatomy Biology Chemistry Physics Other:

V. Extracurricular Activities

Indicate the activities you are currently involved in at your high school or within your community.
Community Service:
Athletics/Band:
Clubs:
Work:
Others:
Activity Name Days of the Week/ Time of Activity

VI. Academic and Career Goals

Please answer the following questions in your own words. Your response to these questions will help us assess your strengths and weaknesses.
Do you plan on attending a trade school? If so, for what field?
Do you plan on attending a college? If so, what major (s) and what degree(s) are you considering?
Indicate your desired Career Goal:


How can the CSUSB Water Resources Institute High School Internship Program help you achieve your goals in respect to academic, career aspiration and/or your personal achievement?

VII. Personal Statement

So we can better evaluate your application, please address the following questions in a personal statement within the space provided below:
·  Who are you? Include information about your grade level, current high school, family, etc.
·  What are your strengths and weaknesses in and out of school?
·  During your free time, what do you enjoy doing? List your hobbies or special interests you have.
·  What are you passionate about?
·  Where do you see yourself in seven years?
·  Why do you want to apply for the High School Intern Program?
·  What do you expect to gain from the High School Intern Program?
If you need additional space, please continue on a separate piece of paper.
VIII. Internship Activities of Interest
Indicate the activities that you are most interested in for the Internship Program (check all that apply):
GIS Training / Use of tablets (i.e. iPads) / Displaying work in museum / Career Exploration
Field Trips / Information sessions on careers / GIS Day / Data collection in field
IX. Parent’s Information- To Be Completed By the Parent or Guardian
Student lives with (check all that apply):
Father / Mother / Stepparent / Grandparent / Other:
Name of Father/ Male Guardian / Name of Mother/ Female Guardian
Employer / Employer
Work Number / Work Number
Father/ Male Guardian / Mother/ Female Guardian
Attended / Completed / Attended / Completed
Elementary
High School
2 year College/ University
4 year College/ University
Graduate/ Professional
X. Certifications
** I certify that the information provided on this application is accurate and complete to the best of my knowledge. I also agree to provide any documentation necessary to verify information reported on this form. **
Student Name (Please Print) / Student Signature Date
Father/ Male Guardian Name (Please Print) / Signature of Father/ Male Guardian / Date
Mother/ Female Guardian Name (Please Print) / Signature of Mother/ Female Guardian / Date

THANK YOU – PLEASE SUBMIT THE COMPLETED APPLICATION TO

Water Resources Institute- 5500 University Pkwy, PL-401, San Bernardino, CA 92407

Tel: (909) 537-7681 Fax: (909) 537-7682

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