2017 New Scholar Application

Breakthrough Birmingham, a partnership with Birmingham City Schools, is a tuition-free, academic advancement program that supports motivated students on the path to college. Scholars commit to the program for three summers, beginning the summer before 7th grade and completing the summer before 9th grade.

Please contact Linn Groft if you have any questions: LGroft@breakthroughcollaborative.org or (205)440-7600.

Final Deadline: June 7, 2017

Email address *
Student Information
Student First Name *
Your answer
Student Last Name *
Your answer
Home Phone Number *
Your answer
Student Cell Phone Number (if any)
Your answer
Student Email Address (if any)
Your answer
Student Address, Street *
Your answer
Student Address, City *
Your answer
Student Address, State *
Your answer
Student Address, Zip Code *
Your answer
Student Gender *
Your answer
Student Birth Date *
MM
/
DD
/
YYYY
Language(s) spoken at home [you may choose more than one option] *
Required
Current School *
Breakthrough provides transportation from your child's school to the program site at Hayes K-8 School in the morning and back in the afternoon. If accepted, will your child ride the bus? *
2017-18 Grade *
Parent/Guardian #1 First Name *
Your answer
Parent/Guardian #1 Last Name *
Your answer
Parent/Guardian #1 Relationship to Student (ex: mother, father, grandmother, grandfather, etc.) *
Your answer
Parent/Guardian #1 Home Phone Number *
Your answer
Parent/Guardian #1 Cell Phone Number *
Your answer
Parent/Guardian #1 Which is the preferred phone number? *
Parent/Guardian #1 Email *
Your answer
Parent/Guardian #2 First name *
Your answer
Parent/Guardian #2 Last Name *
Your answer
Parent/Guardian #2 Relationship to Student (ex: mother, father, grandmother, grandfather, etc.) *
Your answer
Parent/Guardian #2 Home Phone Number *
Your answer
Parent/Guardian #2 Cell Phone Number *
Your answer
Parent/Guardian #2 - Which is the preferred phone number? *
Parent/Guardian #2 Email *
Your answer
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