Personal Information
Name_________________________________________________________________________________
Mailing Address ________________________________________________________________________
Home Telephone Number __________________ Name of Parent _________________________________
Age _______ Special Interests _____________________________________________________________
References
Please include at least one teacher, school counselor or school administrator. (No family members
please.)
Name ___________________________________ Title_________________Contact Number ___________
Name ___________________________________ Title_________________Contact Number ___________
School Information
Home School _________________Age __________ Current
Grade_______________________________
GPA 4.0 Scale (Please include written verification from school counselor) __________________________
Academic Focus: Academic/College Prep Vo -Tech/Direct Employment Undecided
Current Extracurricular Activities __________________________________________________________
Academic Awards_______________________________________________________________________
Current Honors or AP Classes _____________________________________________________________
If you are hoping to attend college upon graduation of High School what field of study are you planning on
entering? ______________________________________________________________________________
Employment Information
Name of Employer__________________________________________ Title ________________________
Number of Hours Worked per Week _______________ Description of Duties ______________________
Please submit with a 200-word essay highlighting your interest and reasons for wanting to become a
member of SSA Team CRUSH 1011
