High School Internship Program Application Checklist 2008–2009



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High School Internship Program

Application Checklist 2008–2009
Applications are not considered complete unless all of the following items are included and submitted on time. Submit all items in one large envelope to Mote. Letters of recommendation should be treated as confidential and included in sealed envelopes.


  1. Completed application form

  2. Three typed essays (See application form for essay topics.)

  3. Notarized medical/press release form

  4. Photocopy of insurance card

  5. Official school transcript (Homeschool students – Please provide the most official grade documentation that is available.)

  6. Two letters of recommendation from academic, extracurricular, or work experience supervisors (e.g. guidance counselors/ teachers, Scout/ 4-H leaders, managers). They should address your dedication and ability to succeed in a hands-on internship program.


Mail or drop-off (NO FAXES) the completed application to:

Mote Marine Laboratory

High School Intern Program Application

1600 Ken Thompson Parkway

Sarasota, FL 34236
Applications are due by 5:00 p.m., Friday, August 22, 2008

Call Amy Fleischer at 941.388.4441, ext. 514 with any questions

Mote Marine Laboratory & Aquarium

High School Internship Program

Application 2008–2009
Student Information:

Name Birthday ___/___/___ Gender ___ Grade ___


Street City Zip Code
E-mail Cell Phone

* Primary communication will be through the student’s e-mail address.
Parent/Guardian Information:

Name(s) E-mail


Street City Zip Code
Home Phone Cell Phone
School Information:

High School County


Activities:

Estimate the amount of time that you spend each week on homework, studying, extracurricular activities, leadership positions and jobs by filling out the table below. You may continue on the



back of this sheet, if necessary.


Activity Name

Fall or Spring

Hours per week

ex. Marching band

Fall

20






















































































































































































Student/Parent Agreement:

I understand that I am applying to be considered for admission into Mote’s High School Intern Program. If selected, I will complete all requirements including meeting attendance, projects, and volunteer hours. I understand that this is a commitment of responsibility, time, energy, and enthusiasm and I will uphold these to the best of my ability.
Signature of Applicant Date
I support my child in their application for Mote’s High School Intern Program. I also support, if applicable, driving my child to and from meetings and volunteer opportunities.
Signature of Parent/Guardian Date
Essays:

Please answer each of the following questions. Each essay should be typed and range between 250-400 words in length. Type your name in the right-hand corner of each piece of paper.




  1. Why are you applying for Mote’s High School Internship Program and what do you hope to gain from your participation?



  2. Which cartoon character do you most resemble and why?




  1. What is your favorite animal and why?



MOTE MARINE LABORATORY & AQUARIUM

EMERGENCY MEDICAL TREATMENT

AUTHORIZATION & VIDEO RELEASE FORM
Student Name Date of Birth / /

Parent/Guardian Name(s)

Program Title High School Intern Program Date of Program 2008/2009 School Year

Student Address City Zip Code

Age Gender Home Phone # Business Phone #

Health/Accident Policy #

Policy Company Name & Address

Emergency Contact Emergency Phone #

Please list ANY physical limitations, medical problems, and special dietary/medical needs:

(Use reverse side, if needed.)

** Please attach a photocopy of the insurance card to this form **

RELEASE AND WAIVER OF LIABILITY: I give permission for Mote Marine Laboratory staff to provide any medical assistance they feel appropriate for my child named above. I also give permission for any emergency personnel to treat my child in the event of an emergency. I will be responsible for any and all medical expenses that may be incurred. In consideration of the right to participate in the Mote Marine Laboratory Education Program, I, for my self and my minor child, have and do hereby assume all risks and will indemnify and hold harmless Mote Marine Laboratory, its employees, trustees, officers, volunteers, and members from any and all liability, actions, causes of action, debts, claims, demands or other liability of every kind and nature whatsoever which may arise from or in connection with my child’s participation in any activities sponsored through MML, whether caused by ordinary negligence or otherwise. This signed agreement will serve as a release or assumption of risks for my heirs, executor and administrators, assigns, or next of kin and for members of my family. If any portion of this release is found invalid, the balance will remain in full legal force and effect.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The undersigned hereby authorizes Mote Marine Laboratory personnel to photograph, film, and/or interview the student during a Mote Marine Laboratory Education Program. To prepare slide presentations, photographs, video tapes, audio tapes, movie films, and computerized multimedia in which the student named above will appear, so as to inform the public about the education programs at Mote Marine Laboratory. All rights, royalties, and materials will belong to Mote Marine Laboratory.



~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I, the undersigned, hereby release and discharge Mote Marine Laboratory from any and all claims and demands arising out of or in conjunction with the use of visual and audio recordings
OR
I, the undersigned, do not agree with the above and do not want my minor child to be photographed, filmed, and/or interviewed for the above purposes.
PLEASE CIRCLE ONE. PLEASE CIRCLE ONE. PLEASE CIRCLE ONE.

Parent/Guardian: You must sign this completed form in front of a Notary Public. Your minor child will not be able to participate unless your signature is witnessed by a Notary Public. Thank you.

NOTARIZED SIGNATURE and PRINTED NAME OF PARENT/LEGAL GUARDIAN
Signature _______________________ Printed Name________________________ Date ________

STATE OF _______________________ COUNTY OF ____________________________

The forgoing instrument was acknowledge before me this ____ day of _________________, 2008, by, ______________________________ who is personally known to me or who has produced _________________________________ as identification who (did) (did not) take an oath.

__________________________________

NOTARY PUBLIC SIGNATURE EXPIRATION

____________________________________ STAMP/SEAL



NOTARY PUBLIC PRINTED/TYPED NAME

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