The Success Institute of America, Inc. (SIA)in Collaboration with The Southern Christian Leadership Conference of New Mexico (SCLCNM) African American Youth Leadership Program
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Anticipated Graduation Date
1.0 to 1.5
1.5 to 2.0
2.0 to 2.5
2.5 to 3.0
3.0 to 3.5
3.5 to 4.0
Are you or will you be the first person in your family to graduate from college?
Yes, I am the first in my family to attend college?
No, at least one other person in my family attended college, but no one graduated.
No, at least one other person in my family attended college, and they did graduate.
No, at least one other person in my family is currently attending college at this time.
Are you legally allowed to be employed in the United States of America?
Yes, I am a United States citizen.
Yes, I am a legal resident of the United States.
Yes, I am on work or student visa that allows me to work in the United States.
No, I am currently not eligible for employment.
What makes you uniquely qualified for this opportunity?
Share some of your career or life goals?
How with this internship impact these career or life goals?
What do you know, or what have you heard about the Southern Christian Leadership Conference?
Would you be able to participate in a work internship program during the summer, and possibly during the school year?
If you were a civil rights leader, how would you help the community? What would be your goals and objectives?
This agreement means that I will attend all 10 sessions, arriving on time, properly attired, and prepared to learn. I will address all issues of discussion in a respectful manner, always seeking to understand rather than challenge and to treat all people involved in a respectful manner. I understand that drugs, tobacco, alcohol, or weapons will not be tolerated in the program. I understand that when I complete the program, abiding by all rules and policies, I will receive an incentive pay of $200.00 ($20.00 per session). A $20.00 deduction will be made for each session missed. I accept this opportunity and the challenge presented by the Success Institute of America, Inc. and the Southern Christian Leadership Conference of NM African American Youth Leadership Program. I realize that this is a unique opportunity for me to develop personally and professionally.
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