SFSU Project SHINE Student Intake Form

Students participating in SHINE should submit the Student Intake Form before the registration deadline. Information contained within this intake form is a powerful tool in the process of site placement. For more information about this intake form please contact our National Office at 215.204.3675.

Contact Information

First Name: *

Last Name: *

Phone Number: *

Please do not inlcude dashes (ex: 2125555555)

Alternate Phone Number:

Please do not include dashes (ex: 2125555555)

Email: *

Current Address

Street: *

City: *

State: *

Zip: *

Permanent Address

Street:

City:

State:

Zip:

Birthdate: *

Ethnicity/Ethnicities:

If multiple separate by comma(s)

Languages Spoken Other Than English: *

If multiple seperate by comma(s)

Highest Level of Education Completed: *

Academic Major(s): *

If muliple separate by comma(s), if none specify undeclared

Do You Have Experience With ESL?:

Yes

If yes explain below

ESL Experience:

Describe previous experiences with ESL

Do You Have Experience Working With Elders?:

Yes

If yes explain below

Experience With Elders:

Describe relevant experiences in working with elders

Would you like to be added to the Project SHINE Facebook Group?:

Yes

Project Shine
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CCSF CSU Fullerton Hamilton College Hawaii Partnership Metro State University SFSU SJCC Temple University Utica College Sign up for our Email Newsletter For Email Marketing you can trust	Home SFSU Project SHINE Student Intake Form Students participating in SHINE should submit the Student Intake Form before the registration deadline. Information contained within this intake form is a powerful tool in the process of site placement. For more information about this intake form please contact our National Office at 215.204.3675. Contact Information First Name: * Last Name: * Phone Number: * Please do not inlcude dashes (ex: 2125555555) Alternate Phone Number: Please do not include dashes (ex: 2125555555) Email: * Current Address Street: * City: * State: * Zip: * Permanent Address Street: City: State: Zip: Birthdate: * Ethnicity/Ethnicities: If multiple separate by comma(s) Languages Spoken Other Than English: * If multiple seperate by comma(s) Highest Level of Education Completed: * Academic Major(s): * If muliple separate by comma(s), if none specify undeclared Do You Have Experience With ESL?: Yes No If yes explain below ESL Experience: Describe previous experiences with ESL Do You Have Experience Working With Elders?: Yes No If yes explain below Experience With Elders: Describe relevant experiences in working with elders Would you like to be added to the Project SHINE Facebook Group?: Yes No
Sponsored by: Project SHINE The Intergenerational Center at Temple University 1601 N. Broad Street Suite 206, Philadelphia, PA 19122 Phone (215) 204-3212 \| Fax (215) 204-3195