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Tuskegee University 2019 STEM BUILDERS Academy Application Form for Peer Mentors
Peer Mentor Information
*
Indicates required field
Name
*
First
Last
Enter the name of the student who is applying for admission to the BUILDERS Academy
School (school attending Fall 2019)
*
Booker T. Washington High School (Macon)
Central High School (Phenix City)
Lee High School (Montgomery)
Notasulga High School (Macon)
Select the school your student will be attending in the 2019-2020 academic year.
Student school ID
*
Enter the ID number that identifies your student in his/her school district
Grade (in Fall 2019)
*
11
12
Enter the grade your student will be starting in Fall 2019
Cumulative GPA
*
Enter student's cumulative high school GPA
Citizenship
*
U.S. Citizen
U.S. Permanent resident
Students must be eligible to work in the United States in order to receive a stipend.
Year of participation in the BUILDERS Academy:
*
2017
2018
Peer mentors must have previously attended the BUILDERS Academy as participants.
Gender
*
Female
Male
Race (choose all that apply)
*
American Indian or Alaskan Native
Asian
Black or African-American
Native Hawaiian or other Pacific Islander
White
Prefer not to respond
This information will be used for program reporting and assessment purposes, and does not determine eligibility for the program.
Are you Hispanic/Latinx?
*
Yes
No
Prefer not to respond
This information will be used for program reporting and assessment purposes, and does not determine eligibility for the program.
Why would you like to become a peer mentor?
*
You do not need to write much, 3-4 sentences will suffice.
Contact Information
Mailing address
*
Line 1
Line 2
City
State
Zip Code
Country
Please, enter the address to which information regarding the program can be mailed.
Primary phone number
*
Enter phone number at which student can be contacted (include area code)
Secondary phone number
*
E-mail
*
Enter an e-mail address that you check frequently. Important Academy information will be sent by e-mail.
Medical Concerns
The Tuskegee BUILDERS Academy meets for most of the day and will provide lunch and snacks to peer mentors. Please, let us know whether you have any medical concerns of which we should be aware.
Do you have any food allergies/sensitivities?
*
Yes
No
Please, list any food items that you should avoid due to allergy/medical reasons
*
Are there any medical concerns or daily medications of which we should be aware?
*
Yes
No
If you answered "yes" to either of the questions above, the Academy will reach out to the person listed as primary emergency contact to ensure that your needs are met during Academy days.
Emergency Contacts
If you are selected as a peer mentor, who should we contact in case of an emergency?
Primary emergency contact name
*
First
Last
Please, enter the name of the individual who should be the primary contact in the event of an emergency.
Relationship to student
*
Address (if different from student's)
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
E-mail
*
If the primary contact cannot be reached, who should we contact in case of an emergency?
Secondary emergency contact name
*
First
Last
If possible, provide us with the information for a second individual who can be contacted in the even of an emergency (if the primary contact cannot be reached)
Relationship to student
*
Phone Number
*
By submitting this application, you are declaring that all the information provided in this application is factual and complete. You also agree that, if selected to participate in the Tuskegee BUILDERS Academy, you will take part in all Academy activities as assigned to you by faculty mentors. You also acknowledge that failing to satisfy any of these requirements will lead to loss of the stipend and/or termination of your contract as peer mentor.
After you submit your application, you should see a message confirming that the application was successfully submitted. If you do not see this confirmation message, your application was not received and you need to submit it again.
If
you continue to have problems submitting your application, please use our
Contact Form
or e-mail us at
TuskegeeBuildersAcademy@gmail.com
.
Acknowledgments
*
Student and guardian have discussed and understood the terms of application
Submit Application
You can also download the application, fill it, and submit it by email or postal mail by clicking
here
.
HOME
PROGRAM INFORMATION
WHAT IS THE BUILDERS PROGRAM?
ELIGIBILTY & APPLICATION
>
INFORMATION FOR STUDENTS
INFORMATION FOR TEACHERS
ATTENDING THE ACADEMY
NEWS & UPCOMING EVENTS
Calendar of events
Program Newsletter
Subscribe to the Newsletter
RESEARCH
CONTACT US
