MESTIZO ARTS & ACTIVISM

COLLECTIVE

LEGISLATIVE SESSION INTERNSHIP *Application Due JANUARY 9, 2012*

PERSONAL INFORMATION:

Name: _____________________________

School: ____________________________

Address: ________________________________________________________________ Home Phone: _______________________ Cell Phone: ________________________

Email: __________________________________________________________________ MySpace URL/Facebook (optional): _________________________________________ Gender: Female: ___ Male: ___

Ethnic Origin (optionalselect below): ___ ___ ___ African American/Black Latina(o)/Hispanic Caucasian/White ___ ___ ___ Asian American/Pacific Islander Native American/American Indian Multiracial/Biracial

**Please answer the following questions within the space provided**

___ Current Grade:

Other:_______________ ____ 9th ____ 10th ____ 11th ____ 12th

EMERGENCY CONTACT:

Name: _____________________________ Daytime Phone: _____________________

Relationship: ______________________ Work/Cell Phone: __________________

Please contact Matt Bradley (matt.bradley@honors.utah.edu, 801-792-5917) with any questions or for more information. 1. What are your other extracurricular commitments & community projects that you are involved in?

2. Describe any interests or experience you have with journalism?

3. What is your interest in politics or learning more about the political process?

Applicant Signature: ___________________________ Date: ________________

**Note: Parental permission will be necessary in order to participate in this program.

4. What do you think are the most important issues for young people today?

5. What does civic engagement mean to you?

Please email your application to: matt.bradley@honors.utah.edu or, Deliver it to: Matt Bradley Honors College 1975 de Trobriand Salt Lake City, Ut 84113 Directions: http://honors.utah.edu/people/contact-us or, Call us to make another arrangement. For additional information or questions regarding the project, contact: Matt Bradley (801) 792-5917

**Please answer the following questions within the space provided**

Please include the name and telephone number for one personal reference (teacher/family friend etc.) who we may contact:

Name: ______________________________

Telephone Number: _____________________

Applicant Signature: ___________________________ Date: ________________

**Note: Parental permission will be necessary in order to participate in this program.