Application

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Section 1: Biographical Information

Applicant Information

Your Name (required)

Nickname or Preferred Name

Date of Birth (mm/dd/yyyy) (required)

Social Security # (required)

 

Mailing Address (required)

Billing Address (if different)

Home Phone (required)

Cell Phone

Your Email (required)

I am applying for:

Family Information

Parent/Guardian 1 Name

Home Address

(if different)

Home Phone

Fax

Cell Phone

Business/Profession

Title

Employer

Business Address

Business Phone

E-mail

Parent/Guardian 2 Name

Home Address

(if different)

Home Phone

Fax

Cell Phone

Business/Profession

Title

Employer

Business Address

Business Phone

E-mail

Parents’ Marital Status (relative to each other)

With whom do you make your permanent home?

Other

Citizenship

Other Citizen Visa Type

Alien Registration Number

Education

High School/Address

Years Attended

Name of College Counselor


Other High School(s) attended (if applicable)

High School Name

Years Attended


High School Name

Years Attended

College Name/Address (if applicable)

Years Attended

How did you hear about Dynamy?

Please be specific (ie. name of college counselor or friend, web research, etc.)

Section 2: Self Assessment

We each have our own unique strengths to build upon and challenges to overcome. When answering the following questions please think about your personality and your talents.

Short Answers

Please list your strengths

Please list your challenges

Learning Style
 Hands-on Kinesthetic Auditory Visual

Other(s)

Please rate yourself against other students your age in the following categories

  Excellent(top 10%) Above Average Average Below Average Poor(low 10%)
Honesty  1  1  1  1  1
Reliability  1  1  1  1  1
Maturity  1  1  1  1  1
Initiative  1  1  1  1  1
Follow Through
Self-Confidence  1  1  1  1  1
Self-Advocacy  1  1  1  1  1
Self-Discipline  1  1  1  1  1
Positive Leadership  1  1  1  1  1
Good Decision Making  1  1  1  1  1
Valuing Differences  1  1  1  1  1

Internship Year Skills Assessment

How would you describe your abilities in the following categories? (please check one box for each skill and briefly describe your abilities in those categories where you’ve checked either “strength” or “challenge”)

  Strength Neither Strength nor Weakness Challenge
Organizing your Belongings  1  1  1
Scheduling Your Time  1  1  1
Prioritizing Tasks and Goals  1  1  1
Completing Tasks on Schedule  1  1  1
Creatively Solving Problems  1  1  1
Communicating with Peers  1  1  1
Communicating with Older Adults  1  1  1
Contributing Positively to Groups  1  1  1
Reflecting on Past Experiences  1  1  1
Accepting Feedback  1  1  1
Providing Feedback to Others  1  1  1

Optional – Supplemental Information

Section 3: Activities and Interests

Activities

Please list all activities in which you have participated during the past 4-5 years. Include all school, community, summer, volunteer and employment activity. Be sure to list any official positions you’ve held and awards you’ve earned. We are particularly interested in how valuable you found each experience, therefore, please rate each activity on a 1-3 scale where 1 = of little value and 3 = highly valuable to you.

Activity Positions/Awards Time Period (start date –end date) Time Commitment (avg. hrs./wk.) Importance (1 = low – 3 = high)
Interests

Please select among the following general categories the types of internships that you may choose during your Internship Year. Rate only the categories that you think you may choose during your Internship Year.

  Mild Above Average Strong
Animal Care  1  1  1
Architecture  1  1  1
Arts & Culture  1  1  1
Athletics  1  1  1
Auto Mechanics  1  1  1
Business  1  1  1
Early Childhood Education  1  1  1
Communications/Media  1  1  1
Craftsmanship/Design  1  1  1
Culinary/Restaurant Management  1  1  1
Education  1  1  1
Engineering  1  1  1
Environment  1  1  1
Finance  1  1  1
Government/Civic  1  1  1
Health Care  1  1  1
Human Services  1  1  1
Information Technology  1  1  1
Law  1  1  1
Other
 1  1  1
 1  1  1

Section 4: Essay

Essay

Tell us why you want to do Internship Year. What do you hope to do with your time here and how do you hope to grow from the experience? (Your essay should be minimum 300 words)

Word count: 0

Supplemental Media (optional)

If you feel that also expressing yourself with another format (i.e. video, digital recording, artwork, etc.) would help us get to know you better, please feel free to submit it in addition to the required written essay.

Section 5: Transcripts & Placement Tests

Transcripts

Please request that your academic transcripts, high school and college (if applicable), be sent to the Dynamy Admissions Department, 27 Sever Street, Worcester, MA 01609. Or E-mail admissions@dynamy.org

College Placement Tests

If you have taken the SAT I, SAT II, TOEFL and/or ACT, and it WILL NOT appear on your transcript, please report those scores here. Report only your highest score on each test and subtest and list the test date for each of those scores.

Test/Subtest Score Test Date

Have you taken any other college placement tests? Explain.

Section 6: Educational Testing & IEP/504

If, in the past two years, you have participated in psychoeducational testing (ie. Wechsler, Woodcock-Johnson, etc.), and had an Individual Education Plan or a 504, we encourage you to provide those documents so that we may support you from a more complete understanding of your individual strengths, challenges and abilities.

 1

Yes, I have an Educational Testing Plan and/or 504 Plan.

I will mail a hardcopy to Dynamy or hand deliver it when I visit.

 1

No, I will not be submitting these documents.

 

Dynamy
Attn: Francine Kupferman
27 Sever Street
Worcester, MA 01609

Section 7: Recommendations

Dynamy requires two recommender. One academic and one community.

If you are not able to identify two people who fit these categories, please contact Dynamy admissions to discuss alternatives.

Academic Recommender

i.e. School Guidance Counselor, Teacher (any subject), Tutor, School Administrator (Principal; Dean of Students; etc.)

Name

E-mail

What is your relationship?

According to the Family Education Rights and Privacy Act of 1974, you will waive the right to review your educational records. Please indicate whether or not you waive the right to access this recommendation.

Applicant Name

Community Recommender

i.e. Employer/Supervisor, Coach, Art Instructor, Band/Chorus Director, Camp Administrator, Religious Leader, Troop Leader

Name

E-mail

What is your relationship?

According to the Family Education Rights and Privacy Act of 1974, you will waive the right to review your educational records. Please indicate whether or not you waive the right to access this recommendation.

Applicant Name

Section 8: Personal History

As part of our programming we can often provide a number of additional supports for student success. Please help us by answering the following YES or NO questions. If you answer YES to any of these questions, please attach another page and explain the circumstances as well as what you have learned (optional). We reserve the right to request further information and to speak with professionals who you have worked with while addressing any such matter in order to best understand its implications, if any, for your participation in any aspect of the Internship Year program. All information and personal disclosure will be kept strictly confidential.

In the past three years, have you
Been asked to leave school, summer camp or another program?
Been treated for any physical or psychological condition that severely limits your participation in any activity?
Been arrested for any criminal offense?

Reminder: For any YES answer, please explain the circumstances as well as what you have learned on a separate sheet of paper (optional).

Section 9: Supplemental Information (Optional)

Photo

Please provide a profile picture.

Section 10: Certifications & Signatures

Applicant

I certify that all of the statements made in this application are true, correct and complete, to the best of my knowledge, and are made in good faith. I understand that misinformation or omission of information could result in disqualification and/or termination of my enrollment in Dynamy Internship Year. Furthermore, I take full responsibility for my medical, psychological and physical condition for the duration of my Internship Year. I am unaware of any further medical, psychological or physical conditions that might inhibit my ability to fully participate in the program. Should any problems arise during the course of the program, I will promptly notify an Internship Year staff member.

 I hereby certify the above
I hereby certify the above

Applicant’s Name (required)

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