Southside Voices Youth Media Fellowship Application
Complete this form to apply for the youth media fellowship and share your interests and availability.
Applicant Information
Applicant Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
School Name
*
Grade Level
*
Please Select
9th Grade
10th Grade
11th Grade
12th Grade
City/County
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Relationship to Applicant
*
Please Select
Mother
Father
Guardian
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Acknowledgment of Time Commitment
Parent/Guardian Signature and Date
*
Availability
Weekday afternoons available?
*
Yes
No
Weekday evenings available?
*
Yes
No
Weekends available?
*
Yes
No
Scheduling conflicts during the program period
Interest and Participation Questions
Why are you interested in participating in the Southside Voices Youth Media Fellowship?
*
What topics in your community would you like to help highlight or discuss?
*
Describe a time when you worked as part of a team or group and what role you played.
*
What skills do you hope to learn or improve through the fellowship?
*
Commitment Statement
Commitment Statement
Applicant Signature
*
Date
*
-
Month
-
Day
Year
Date
Optional Information
Have you participated in media, journalism, podcasting, or public speaking before?
Yes
No
If yes, briefly describe your experience
Submit Application
Submit Application
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