SMI Student Application Form

[[media:SMI Student Application Form.odt|Download an opendocument format version of this form.]]

Scholarship Mentoring Programme 2009: Student Application Form

''Complete and return this form (signed). Then with your school’s SMI Coordinator you will need to complete the online registration (by Friday 19 June). ''

Student’s Full Name:

School Attended:

Student’s NZQA NSI:

Student’s Email address:

The programme will commence in the week beginning Monday 20 July 2009. 45 minute video-conferences will take part between 3.20pm until 4pm and 4.05pm and 4.55pm (unless indicated otherwise.)

All students who enrol must pay a single $150 SMI registration deposit. Payment should be by cheque made out to: OtagoNet SMI 2009 and be handed into your school’s SMI coordinator along with this form.

Student’s signature and Date:

Parent/Caregiver’s signature and Date:

Principal’s Signature and Date: