Akili Fellows Programs 2018 Deadline to Apply is April 23, 2018 APPLICATION: Name* First Last Date of Birth* Age*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Phone Number*Additional Contact Phone NumberHow did you find out about the Camp Akili summer camp?*Have you served as a Camp Akili counselor in the past?YesNoSchool Information: Highest Education Level Achieved*High SchoolAttending 2-Year CollegeAttending 4-Year CollegeCollege Graduate (2-Year)College Graduate (4 Year)Attending Graduate SchoolPost GraduateCollege/UniversityYear in SchoolCurrently Declared MajorHave you had direct experience with any of the following? Drug or substance abuse challenges Physical, mental, sexual or emotional abuse Arrest or convictions Depression, or anxiety If you answered yes, to any of the above experiences please explain.Have you participated in any leadership development/training courses, classes, seminars, workshops, etc.?YesNoIf yes, please list the content, date and place of each training experience.Gender IdentitySexual Orientation (optional)Race/Ethnicity (Optional)Black/African AmericanWhiteNative American/American IndianHispanic/LatinoAsian/Asian AmericanWork and Volunteer Information: Please list any experiences you have had working with youth.Why are you interested in becoming a Camp Akili Counselor?*T Shirt Size*smallmedlargeX-Large2XLEmergency Contact Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Emergency Contact Phone Number*Relationship*Upload Your Resume (Optional) Drop files here or Accepted file types: pdf, doc, docx, gif, png, jpg.