Governor’s school for scientific Models and data analysis
East Tennessee State University Application for Governor’s School Resident Counselor
Personal Data:
Name:
Last
Permanent Address:
Number & Street :
City State Zip :
Phone:
First
Middle
Home
Cell
Area code & number
Area code & number
School Name:
Address:
Number & Street :
City, State Zip :
School Phone:
Email:
Email:
Social Security #:
Date of Birth:
Area code & number :
PERSON TO NOTIFY IN CASE OF EMERGENCY:
Name:
Address:
City:
State:
Phone:
Zip:
Educational Background:
High School from which you graduated:
Date of graduation:
Colleges and Universities you have attended:
Name of College
Attended From:
To:
Degree (s) earned:
Current Degree sought:
Major GPA:
Current student classification: (check one)
Freshman
Sophomore
Junior
Senior
Graduate
Other
Governor’s school for scientific Models and data analysis
East Tennessee State University Application for Governor’s School Resident Counselor
GENERAL INFORMATION:
Have you ever lived in an East Tennessee State University Residence Hall?
Have you ever lived in a Residence Hall on another campus?
Yes
Yes
No
No
If Yes, How long?
If Yes, How long?
What experience have you had working with young adults and/or teenagers? (I.e. camp counselor, water safety
instructor, and other counseling responsibilities:
What qualities and attributes do you feel you have which would be helpful in performing the duties of the position
you are applying for and what are your expectations from the position?
What memberships or leadership position have you held in a residence hall, on a college campus, or in your
community? Please include educational, professional, religious or social organizations.
What are your plans professionally? What type of work do you wish to do?
EMPLOYMENT DATA:
List the most recent jobs you have held, including part-time, summer work, and volunteer:
Name of Organization
Position Held
Dates Held
Supervisor
Phone #
Governor’s school for scientific Models and data analysis
East Tennessee State University Application for Governor’s School Resident Counselor
REFERENCES: (Please Print)
List the names and addresses of three (3) people who know you and your work. Include employers, college counselor/advisor, faculty members,
department head or others with whom you have worked, who could evaluate your potential success as a Governor’s School residence hall staff
member. Give office phone numbers including area code. (Include the names of the Resident Advisor on your floor if living in the Residence
Hall)
Name:
Title:
Address:
Phone:
Name:
Title:
Address:
Phone:
Name:
Title:
Address:
Phone
Your Signature: __________________________________________________ Date: __________________________
Note: You’ll need to print 3 copies of the reference form.
Note: Complete application and copy of college transcript should be returned by February 1st to address below or can be
emailed to [email protected] :
Governor’s school for scientific Models and data analysis
Center of Excellence in Mathematics and Science Education
East Tennessee State University
Attention: Angela Haga
P.O. Box 70301
Johnson City, TN 37614
Phone: (423)439-7592
Fax: (423)439-7530
Visit the website at: http://www.etsu.edu/cas/math/mathexcellence/govschool/default.aspx