2018-2019 Garden State MOSAIC Application

2024-2025 Garden State MOSAIC Applications Now Being Accepted

Garden State MOSAIC is a free, youth educational and leadership program offered to teens in the 8th - 12 grades. Prospective students must submit application forms by Sunday, October 15, and a selection process is used to assure adequate diversity and balance in the program. Most program sessions are held at locations in Central Monmouth County. Sessions are conducted on Sunday afternoons, from 3:00 - 5:00 p.m., roughly every other week (adjusting as needed for holidays). Students have the opportunity to earn volunteer service hours for each session and special service projects attended. They are eligible to get a completion certificate if they attend 60% of the year's faith sessions and participate in at least one of the special service projects.

The kickoff session is being planned and will be announced shortly. This session is MANDATORY for all participants.

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

What grade are you in?

What school do you attend, in what town?

Gender

MaleFemalePrefer not to answer

Cell Phone Number*

Area CodePhone Number

E-mail*

Parent's/Guardian's Name*

Parent Guardian First NameParent Guardian Last Name

Parent's/Guardian's Phone Number*

Area CodePhone Number

Parent's/Guardian's E-mail*

Please indicate a culture or nationality that you associate with. NOTE: You can say, "prefer not to answer".

Please indicate a race that you identify with (Caucasian, African, Asian, Latino or other). NOTE: You can say, "prefer not to answer"

If you subscribe to a particular Belief System, Religion, or Faith, please tell us which. NOTE: "none" or "undecided" is an answer.

How did you hear about Garden State MOSAIC?

A family member or friend has been involved in the past.My parent heard about MOSAIC and suggested that I apply.My clergy suggested that I apply.My guidance counselor suggested that I apply.I learned about MOSAIC on social media, or in traditional media.I met an Alumni Ambassador.I saw a flyer hanging in the school or library.I am an alumnus.Other

Please tell us why you want to participate in Garden State MOSAIC and what you hope to get out of the program.*

Do you have any allergies or do you require any special accommodations we should know about?

I understand that getting a completion certificate involves attending at least 60% of the sessions and participating in at least one of the service projects scheduled throughout the year..

YES.NO.

Is this your first year attending MOSAIC?*

YesNo

Please note, that if you are selected to participate in Garden State MOSAIC, you will be asked to agree to make every effort to attend the majority of sessions and to respect your fellow students and all those involved. These expectations can be found on our website, and will be distributed at our first meeting.