SMI Student Application Form

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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:

Scholarship Mentoring Tutorials being offered in 2009:
Art History Biology Calculus
Chemistry Economics Geography
Graphics History (England option) History (NZ option)
Physical Education English Statistics & Modelling
SMI Subject you wish to enrol in
HOD’s Signature

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: