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2024 P.E.A.R.L.S. Mentoring for Girls, Inc. New Member Application
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23
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1
P.E.A.R.L.S. Chapter of Interest
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Holmes County Chapter
Leflore County Chapter
Hinds/Madison County Chapter
Memphis Chapter
Bolivar County Chapter
Leake County Chapter
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Please Select
Holmes County Chapter
Leflore County Chapter
Hinds/Madison County Chapter
Memphis Chapter
Bolivar County Chapter
Leake County Chapter
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2
Full Name
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First Name
Last Name
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3
Age
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4
Date of Birth
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Date of Birth
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Day
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5
Participant Cell Phone Number
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6
Current Grade
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7
Current School Name
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8
Email
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example@example.com
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9
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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10
Parent/Guardian
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First Name
Last Name
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11
Phone Number
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Please enter a valid phone number.
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12
Socio-Economic Status
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Less than $20,000 per year
$20,000 - $40,000 per year
$40,000 - $60,000 per year
$60,000 - $80,000 per year
$80,000 - $100,000 per year
Over $100,000 per year
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13
Parents Highest Level of Education Completed
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No formal education
Some high school
High school diploma or equivalent (e.g.,GED)
Some college or technical/vocational training
Associate's degree
Bachelor's degree
Master's degree
Doctoral degree
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14
Ethnicity
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Asian/Pacific Islander
Black/African American
Hispanic/Latino
White/Caucasian
Native American/Alaska Native
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15
Higher Educational Plans
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List your top 4 colleges.
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16
What career choice are you interested in at this time?
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Choose Top 3 Choices
Architecture and engineering (Architect, Civil engineer, Landscape architect, Sustainable designer, Biomedical engineer)
Arts, culture and entertainment (Singer/songwriter, Music producer, Art curator, Animator/video game designer, Filmmaker, Graphic designer, Fashion designer, Photographer)
Business, Management and Administration (Human resources manager, Marketing assistant, Accountants, Secretary, Entrepreneur/small business owner, Real estate agent, Business development manager)
Communications (Journalist, Copywriter, Communications manager, Public relations specialist, Meeting/event planner, Social media manager, Brand manager)
Community and social services (School counselor, Speech pathologist, Rehabilitation counselor, Licensed clinical social worker, Child welfare social worker, Palliative and hospice care worker)
Education (Special education teacher, School principal, Superintendent, College professor, School librarian, Substitute teacher)
Science and Technology (Archeologist, Software engineer, Laboratory technician, Microbiologist, Physicist)
Installation, Repair and Maintenance (Auto mechanic, Landscaper and groundskeeper, Bicycle repairer, Wind turbine technician, Plumber)
Farming, Fishing and Forestry (Agricultural worker, Animal breeder, Nursery worker, Forest and conservation worker, Fisher)
Government (Cafeteria worker, Congressional staff, National park ranger, Mail carrier, Firefighter)
Health and Medicine (Anesthesiologist, Dental assistant, Nurse, Veterinarian, Physical therapist)
Law and Public Policy (Lobbyist, Public administrator, Paralegal, Lawyer, Labor relations specialist)
Sales (Sales associate, Sales development rep, Account executive, Regional sales manager, VP of sales)
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17
Describe your leadership ability and list clubs, organizations, and/or affiliations that you have been
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18
List scholastic distinctions you have won since being in school (i.e. honor roll, National Merit, etc.)
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19
Please indicate which of the following activities would be of most interest to you as part of the program. (Please check all that apply).
*
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Book Club
Careers
College Life
Etiquette
Health and Beauty
Money/Savings
Nutrition and Exercise
Public Speaking
Self-Esteem
Social Action
Social Media
Study Habits and Homework Tips
Technology
Volunteering
STEM
Other
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20
Please provide a list of ongoing activities in which you will be engaged during the 2023-2024 school year (e.g., clubs, sports, jobs, church and community activities.):
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21
Why do you want to be a part of P.E.A.R.L.S. Mentoring for Girls, Inc. and what do you hope to learn or gain by participating in the program?
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22
Please upload a copy of the P.E.A.R.L.S. Mentoring for Girls, Inc. Candidate's transcript or final report card from the 2023-2024 academic year.
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23
If a member referred you, what is her name?
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