Apply to UR SUCCESS

Apply

Students, aged 15-24, who are motivated to explore career-oriented opportunities and college-level education, are eligible to apply for UR SUCCESS programs.

Students can apply by completing the online application below, printing and mailing the printable form (PDF), or by calling 971-340-5577.

“I just filled out an application.
It was easy. I thought it was
a free job set-up.”

--Marco Depas, 17, heard about UR SUCCESS
and the possibility of help to get him prepared to work.

UR SUCCESS student Jake Peschiera referees youth backetball games at a Portland Community Center.


I want to apply to participate in the UR SUCCESS student internship program.

APPLICANT INFORMATION
	First Name A value is required. Last Name A value is required.
	E-mail A value is required.Invalid format.
	Address
	City	State	ZIP
	Phone Invalid format.	Cell Phone Invalid format.

	Mailing Address (If different than above)
	Address
	City	State	ZIP
	Home Phone Invalid format.	Cell Phone Invalid format.

	Gender:
	Birthdate: A value is required.Invalid format.
	Age: A value is required.Invalid format.

	How did you hear about UR SUCCESS?


	Do you have access to public transportation?	Yes No

PROGRAM & RESPONSIBILITIES
	I am interested in the following programs: Placement will be made as requests are received and space is limited.
	Summer internship/ job placement	Group service project

	Preferred fields of interest: (Mark your first second and third choices.)

	List any medical or physical limitations that might affect your ability to perform this job: (Please note that medical or physical limitations will not necessarily bar you from acceptance.)

	Have you read the information in the brochure, or online, describing the UR SUCCESS summer program? Yes No

	Do you understand the requirements of this program and can you meet them? Yes No

	Are you committed to completing the the program? Yes No



	Have you ever been arrested, or convicted of a crime? Yes No (Please note: positive responses will not necessarily bar you from acceptance.)
	If yes, list dates, location and charges. (Be specific.)

NARRATIVE QUESTIONS
	Instructions: We encourage you to develop your answers in a document first and then make a final copy. Please answer in complete sentences, and check your grammar and spelling. If possible, ask a friend, parent or teacher to proofread your answers. Your final copy should be clearly written or typed. Keep a copy of your answers so you have a record of your reply.

	1. What does success mean to you?

	2. What can you do to reach success?

	3. A goal of UR SUCCESS is to give you the opportunity to experience real work places and projects. What do you want to learn from this experience?

	4. What do you consider your greatest accomplishment? Why was this achievement important to you?

	5. What are your favorite activities that you like to pursue in your free time?

	6. Joining UR SUCCESS means making a commitment to finish what you start, and being able to honor that commitment. Describe a time when you kept your word although it was really hard to do.

CONSENT & AGREEMENT
	Please make a selection.I have read the information about UR SUCCESS and I understand that this job will involve working independently or in groups in private or public locations, will require punctuality and reliability, and the ability to follow instructions. Oregon State law prohibits the use or possession of tobacco products by anyone under 18 years of age. If offered a position with UR SUCCESS, I agree to comply with this law and agree to refrain from the use of alcohol and illegal drugs during my entire program. I certify that I completed this application myself and that all of the statements made in this application are true to the best of my knowledge.

	By completing the "signature and date fields" below your are signing this application.

	Applicant: A value is required.Today's Date: A value is required.Invalid format.

	Parent/Legal Guardian: A value is required.A value is required.Today's Date: A value is required.Invalid format.A value is required.Invalid format.

UR SUCCESS, 1631 NE Broadway St., PMB 352, Portland, OR 97232, 971 340-5577, info@ursuccess.org
For web-related issues, contact webmaster@ursuccess.org