Mental Health Career Pathways Summer Program Application/Permission Form
Section 1 is to be completed by the child applying to participate. Sections 2 through 5 are to be completed by parent/guardian granting the child permission to participate. It should not take more than 5 minutes for the parent/guardian to complete those sections.

Please FULLY complete forms below. Incomplete applications will not be considered. You will be contacted with further instructions and information at a later date. All high school age students (entering grades 9 through grade 12 in fall of 2022) are eligible to apply. You may also apply if you are a 2022 high school graduate.

The summer program will run in two sessions this year. The program will be
Monday through Thursday *(week one runs Tuesday-Thursday due to the July 4th holiday)
July 5th through August 4th from 9AM to Noon or 1pm-4pm each day.  There may be days that are scheduled for different times depending on travel and scheduling of College visits and/or Service opportunities.  Any changes in time will be communicated in advance.                                                          
                                                                                   

Please submit this application form by Friday, June 3, 2022 to be considered.

Questions or need more information? Contact:
Beth Miller, Associate Director, Prevention Awareness Support Services (PASS)
bmiller@passaah.org 
937-645-0141 ex. 201
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Email *
Applicant's full name *
Applicant's Pronouns (If desired)
School district you attend *
Are you involved with your school's Gatekeeper group or the Union County Gatekeeper group? *
County of residence *
Fall 2022 grade level (next school year) *
Applicant age: *
Student's full home address (include street number, street name, city, state, and zip) *
Student's phone number *
What is the best way to contact you if you are selected? *
Cell phone carrier (e.g. Verizon, AT&T, Sprint, T-mobile etc.) *
Which session is your first choice? (You are not guaranteed your first choice as there are 10 spots in each session, but we will do our best to place you in your session of choice). *
T-shirt Size (Adult Cotton) *
Why are you interested in pursuing this opportunity and/or a degree/career in mental health, behavioral health, social work or other related field? Please be as detailed and specific as possible. *
Do you have something specific you would like to learn  or a specific profession you would like to hear about during the program?
What makes you stand out as a candidate to be selected for this program? *
Do you have any plans for summer vacation or other obligations that will hinder your daily attendance? If yes, please explain. Dates/times for the summer program are listed above in the form instructions. *
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