Young&Motivated Profile Form

Please fill in your answers below and click on the SUBMIT button at the end.
All fields are required. This form will be kept strictly confidential

General Information

Name
Birthday
Home Address
City
State
Zip Code
Home Phone
Personal Email (Please do not use school email)
Date of program you're attending June 22-23, 2012 July 13-14, 2012
Are you attending with a family member? Yes No
If yes, what is their name?
What is their relation to you?
Would you like to sit together? Yes No
Will you need any physical assistance while attending Y&M?
Do you have any dietary restrictions or food allergies that we should know about?

Education

High School Student High School Graduate College Student College Graduate
Degree(s) Earned ?

About You

How do you see yourself? Check all that apply: Creative Funny Shy Life of the Party Confident Responsible Easygoing Risk Taker Generous Outspoken Flexible Quiet Optimistic Smart Independent Impulsive Happy Compassionate Determined Adventurous Spiritual Leader
Any we've left out?
What activities do you enjoy? Check all that apply: Playing Sports Shopping Dance Computers Art/Photography Computer/Video Games Reading Time with Family/Friends Outdoor Activities Traveling Playing Music TV/Movies Working Out Church Activities Writing
Other:
Club/groups you're a member of:

More About You

What accomplishments are you most proud of?
What have you done that you are least proud of?

Time

When I had an assignment that I really didn't want to do, I usually: Put it off until the last possible moment Complete it as soon as possible so that I have more time for the things I enjoy Do it in time, but I don't like the end result
If I have an exam coming up, I usually: Study some every day Study for long stretches of time, two or three days before the exam Cram the night before Wing it
Do you use a calendaring tool? Yes No
If so, which type of calendar do you use? (ie. Outlook, smart phone, paper, planner)

Money

I live: alone with a roommate with my spouse/family with my parents
Do you rent or own? Rent Own
Do you have a car? Yes No
About how much do you spend in a month?
How much do you owe for school loans, credit card?
Do you find it easy to save money? Yes No
Are you comfortable with the money you have? Yes No
If not, how much more per month would make you comfortable?
Do you feel you need to change the way you manage money? Yes No
If yes, please explain:

Relationships

Do you have a mentor? If so, who? Why is this person your mentor?
Do you find it difficult to socialize with new people? Why or why not?

Vision

Without considering pay or school, which three careers do you think would make you happiest?
Now considering pay and education, which three careers do you think would make you happiest?
What three things are most important to you in a job?
Briefly describe what you'd like your life to be like in 5 years. Where would you live? What job would you have?
What five things do you hope to learn from Young&Motivated?

Thanks. Your answers will be kept confidential and will be used to customize the program to your needs.

Please enter the characters below into the box provided and click SUBMIT.

For more information, please call 800.743.5694