Student Registration
Thank you for your interest in participating in CREATE Mentoring, a program of the SRBX Education Foundation. Please complete all fields below. For questions when completing this form, please contact Katie Carbone at kcarbone@srbx.org or 916.465.8346.
School Year *
Required
First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Student Phone Number *
Your answer
Parent Phone Number *
Your answer
Student Email Address *
Your answer
Parent Email Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Ethnic Origin (check all that apply) *
Required
Type of High School *
Name of High School Where I am Participating in CREATE *
Your answer
Current Cumulative GPA *
Your answer
Current Grade Year *
Expected Graduation Year *
Your answer
Industry Interests (Check all that apply) *
Required
How Many Years Have You Been a Participant of CREATE?
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