SUCCEED 2013 Student Workshop
Please enter in the following information for registration to the SUCCEED 2013 Student Workshop
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First Name *
Please enter the following information for yourself:
Last Name *
Date of Birth *
Street Address *
Apartment Number/Suite Number/Office Number
City *
State *
ZIP/Postal Code *
Email Address *
First Name *
Please enter the following information for your Father/Guardian:
Last Name *
Address *
Apartment Number/Suite Number/Office Number
City *
State *
ZIP/Postal Code *
Email Address
Phone Number *
First Name
Please enter the following information for your Mother/Guardian:
Last Name
Address
Apartment Number/Suite Number/Office Number
City
State
ZIP/Postal Code
Email Address
Phone Number
Name *
Contact person to be reached in event of an emergency, if parent or guardian is unavailable
Relationship to applicant *
Phone Number *
Are you entering 10th grade in Fall 2013? *
Please enter the following information for your registration consideration
School you attended this previous year? *
School you will attend this coming year? *
Please list the math and science classes you took in 8th and 9th grades *
Ethnicity (optional for demographic purposes)
Describe one of your science projects or your favorite science experiments from a class you have taken.  What was fascinating about it?  What would you change?  How could you build off of it? *
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