Section 1: Personal Information
Name *
Name
Date of Birth *
Date of Birth
Home Address *
Home Address
Phone *
Phone
Do you receive free or reduced lunch? *
Student lives with (check all that apply) *
Parent/Guardian 1 Name *
Parent/Guardian 1 Name
Work Phone
Work Phone
Cell Phone *
Cell Phone
Parent/Guardian 2 Name
Parent/Guardian 2 Name
Work Phone
Work Phone
Cell Phone
Cell Phone
Section 2: Additional Information
Section 3: Student Essay
Please answer the following questions in 100-200 words:
Section 4: Parent Question
Please answer the following question in one paragraph
Section 5: Teacher or Counselor Reference
Please provide information for a teacher or counselor we can contact. You should also notify them that you gave us their information
Name *
Name
Section 6: Electronic Signature
I certify that the information provided in this application is complete and accurate to the best of my knowledge. Falsification of any information will cause disqualification from the program. Acceptance of the program's membership constitutes permission to use the recipient's name and/or likeness for public relations purposes.
Today's Date *
Today's Date