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
Sign in to Google to save your progress. Learn more
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.) *
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. *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of PVFF. Report Abuse
Google Forms