JA Fellows - Student Application for the 2011-2012 School Year

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JA Fellows Student Application for the 2011-2012 School Year

Personal Information:

First Name:

Middle Name:

Last Name:

Gender:

Female Male

Birth Date:

Student E-mail:

Confirm E-mail:

Home/Primary Phone:

Student Mobile Phone:

Demographic Information:

Information pertaining to Ethnicity/Race, Income Level, and Test Scores has no bearing on acceptance; however, it assists us with grant compliance and reporting to donors, which make the JA Fellows program possible.

Ethnicity/Race:

Education Information:

High School Name:

School Phone Number:

Address:

City:

State:

Zip:

Grade Level for the 2011-2012 school year:

* PARENTS/GUARDIANS PLEASE READ AND COMPLETE THE CONSENT AND INFORMATION SHEET. FAILURE TO COMPLY WILL RESULT IN APPLICATION BEING CONSIDERED INCOMPLETE. You may access the Consent Form here.

Parent/Guardian Name:

Relationship:

E-mail is one of our primary means of communicating information pertaining to the JA Fellows program. Checking your e-mail, the blog & the JA Fellows website regularly will ensure your student's success.

Parent/Guardian E-mail:

Confirm E-mail:

2nd Parent/Guardian E-mail:

Home/Primary Phone:

Work Phone:

Mobile Phone:

Please ensure that your mailing address is accurate. Should your address change, please notify us immediately to update your record.

Permanent Home Address:

Address:

City:

State:

Zip:

Mailing Address:

Address:

City:

State:

Zip:

You must have valid and consistent transportation and be able to attend your scheduled sessions. Our Intown Atlanta locations are MARTA accessible.

I understand that I will attend all scheduled sessions, barring unforeseen circumstances, and that JA Fellows staff & volunteers must be notified in advance of any planned absences. I also understand that should my attendance falter or should my behavior not reflect the high standards of the JA Fellows, my position in the program will be forfeit.

My parent/guardian has read and signed the online parent information and consent form. Click here for Consent Form.

I have informed my Recommender that I am applying to the JA Fellows program, and have asked him/her to complete the online Recommendation Form. Click here for Recommendation Form.

Please ensure that JavaScript is enabled on your internet browser. Otherwise, the application form may not submit correctly.

If you click "Submit" and nothing happens, please review the application for any red text. This will indicate fields which need to be corrected before you can submit the application.

If you successfully complete this process, you will receive an automatic e-mail confirmation of your submission (sent to both the Student & Parent/Guardian e-mail addresses provided in the application). If you do not, or are still experiencing difficulties with the application process, please e-mail jcompton@georgia.ja.org (or call 404.257.1932 ext 209) and describe the nature of the problem.

Regarding photographs & video taken during the duration of the JA Fellows (JAF), all appropriate and necessary permissions and consents by program participants are implied and sufficiently obtained by willing registration and/or attendance at all JAF events held in 2011-2012, including without limitation any copyright licenses and waivers of attendee's rights of publicity or rights of privacy. By attending the JAF, participants or their representatives, agree to not make claims against the JA Fellows (JAF), Junior Achievement of Georgia (JAG), or the photographer(s)/videographer(s) taking pictures and/or video on behalf of JAF or JAG, as a result of the use, publication or reproduction of their photographs and/or videos. In no event shall JAF, JAG, or the photographer(s)/videographer(s) that takes pictures and/or video on behalf of JAF or JAG, be liable for any indirect, incidental, consequential, special, or exemplary damages or lost profits due to use, publication or reproduction of said photographs and/or videos, even if JAF, JAG, or the photographer(s)/videographer(s) that take pictures and/or video on behalf of JAF or JAG, have been advised of the possibility of such damages.

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