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Sltw-teen-interest-profile SLTW Teen Interest Profile

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Salt Lake Teens Write:
Teen Interest Profile
Thank you for your interest in Salt Lake Teens Write! Please return this form to the SLCC
Community Writing Center (CWC), 210 E. 400 S., Suite 8, Salt Lake City, Utah 84111 or email to
cwc@slcc.edu. Please be sure you also return the following forms to the CWC along with your
application: Teacher Recommendation, Parent/ Guardian Consent and Publicity Release.
Salt Lake Teens Write pairs local teens with adult mentors who use writing in their daily and
professional lives. These mentoring teams will work together for one full academic year, meeting
one-to-one for at least one hour a week. The teams will also meet on a quarterly basis with the
other participants in the Salt Lake Teens Write program for a variety of workshops and public
readings. Teens are responsible for their own transportation to/from all Salt Lake Teens Write
activities.
Date of Application
Name Nickname
Street
Address
City State Zip
Home Phone Mobile Phone
Do you have regular access to email at home and/or at school?
Y
es
No
If yes, what is that email
address?
School You Attend:
School Address:
Are you available to meet with a mentor for one hour each week from September 2015-June
2016?
Yes
No
Are you available to meet four times a year (quarterly) on a Saturday for three hours?
Yes
No
Do you have any health conditions we should be aware of?
Yes
No
If yes, please describe:
Sex
Female
Male
Year you were born
Will you be in 11th Grade in
2015-2016?
Yes
No
Ethnic Background (please mark all that apply)
African/ African-American/ Black
Asian
Caucasian
Pacific Islander
Arabic/ Middle Eastern
Native American/ American Indian/ Alaskan Native
Hispanic/ Latino/ Latina
Other
Is English your first language?
Yes
No
If English is not your first language, which language/s do
you speak at home?
Average Yearly Household Income:
$0-6,000
$6,001-12,000
$12,001-30,000
30,001-50,000
50,001-75,000
75,000+
How did you you hear about Salt Lake Teens Write?
What types of reading and writing do you like to do and why?
Please submit, along with this form, a one-two page essay. Tell us why you'd like to be part of
our program. What do you hope to get out of this experience? Don't worry--this is not a "test,"
and you don't have to type it. We just want to get to know you and see what your writing is like
to match you with the best mentor.
Commitment Statement
I understand that Salt Lake Teens Write is a voluntary program that I am choosing to participate in. I
understand the benefits I will receive from this program depend on my willingness and ability to
participate fully in the activities (mentoring team, group writing workshops, blog discussions, etc.) I
am committed to doing the best that I can to fully participate in all aspects of this writing mentoring
program.
Signature Date
T
yping your name here in an electronic format indicates a legal signature.
Thank you for your interest in Salt Lake Teens Write!
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Sltw-teen-interest-profile SLTW Teen Interest Profile

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Completed 17 November 2019

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