ROLE MODEL PROGRAM

 Student Application for Admission

This is the Student Application for Admission into the Juvenile Justice Role Model Program.  This application is necessary in order to officially become a Role Model Student and qualify for the Internship and Juvenile Justice Certificate. Once you have completed the application, click Submit at the bottom of the page to send the application to the Role Model Office. 

Upon receipt and review of the application, a staff member will contact you to inform you of your application status. If you have any questions about the application or other aspects of the Role Model Program, please email the Office.

PERSONAL INFORMATION

Date Application Submitted (mm/dd/yy)

Name
Home Phone
Work Phone
E-mail
Age
Sex Male Female

         Race/Ethnic Background (choose all that apply. Hold ctrl when selecting 2    or more)

White
Black
Hispanic
Asian
Native American

If you are of a racial or ethnic background not listed above, please specify it in the box below.

 SS # 

Have you ever applied for the JJRMDP before?

Yes No

If yes, what semester and year did you apply?

Are you a citizen of the United States?

            Yes    No

If no, where do you maintain your citizenship?

EDUCATION

Please indicate all types of education you have received (use as many forms as necessary).

High School Education

Name and Location of High School

Did you graduate?

Yes No

College Education 

Level of Education

Name and Location of School

College Major

Current Status

Did you graduate?

Yes No

If yes, choose the degree you received

College Education #2 (if applicable)

Level of Education

Name and Location of School

College Major

Current Status

Did you graduate?

Yes No

If yes, choose the degree you received

EMPLOYMENT HISTORY

Please give an accurate, complete full-time and part-time employment record.  Start with your present or most recent employment.

Job #1

Company Name

Company Address

Work Telephone # (555-555-5555)

Name of Supervisor

Employed (MM/YY-MM/YY)

Job Title

Weekly pay beginning and end ($/$)

Description of Job Duties

Reason for leaving

Job #2

Company Name

Company Address

Work Telephone # (555-555-5555)

Name of Supervisor

Employed (MM/YY-MM/YY)

Job Title

Weekly pay beginning and end ($/$)

Description of Job Duties

Reason for leaving

            Job #3

Company Name

Company Address

Work Telephone #

Name of Supervisor

Employed (MM/YY-MM/YY)

Job Title

Weekly pay beginning and end ($/$)

Description of Job Duties

Reason for leaving

MILITARY EXPERIENCE

Have you ever served in the U.S. Armed Forces?

Yes No

If yes, what branch of the Armed Forces?

If yes, describe any Armed Forces training received relevant to the Juvenile Justice Role Model Development Program.

            ADDITIONAL INFORMATION

Please describe in detail any experience or training (other than that listed in the employment section) that you feel would contribute to your ability to be an effective juvenile justice role model.

List any profession or civic organizations of which you a currently a member.

What are your hobbies and interests?

Have you ever been convicted of a crime other than a traffic violation?

Yes No

If you answered yes, please explain the offense.

Describe the qualities that you believe a role model should possess.

REFERENCES

List the names, addresses, and phone numbers of three people that can speak to your ability to be an effective role model.

            Reference #1

            Reference #2

            Reference #3

STUDENT ESSAY

Please write in detail a 400-500 word essay detailing what you feel are the major problems facing our youth and why you believe that you qualify as a role model.

Florida State University Juvenile Justice Role Model Development Program
Copyright © 1999 [JJRMDP]. All rights reserved.
Revised: January 15, 2004