2018 Advanced STARTALK Application
For returning 2017 STARTALK Academy students only. Students will be selected by lottery for the Advanced STARTALK Academies. DEADLINE IS MAY 25, 2018.
6/25/18 - 7/19/18 at Providence Elementary School
(Wednesday, July 4 is a Holiday)
Monday - Thursday 8:00 AM - 12:00 Noon
Student's First Name *
Your answer
Student's Preferred Name (if different than First Name)
Your answer
Student's Middle Name *
Your answer
Student's Last Name *
Your answer
Which STARTALK Academy did student attend last summer? *
Please list any allergy that requires the attention of staff.
Your answer
Please note here if student has been identified as eligible for Special Education services or has an IEP or 504 Plan. Documentation must be provided upon acceptance into the program.
Your answer
What is student's birthdate? *
MM
/
DD
/
YYYY
Will student be in 6th grade in September 2018? *
Which school will student attend in September 2018? *
What is student's gender? *
Will the student take the bus? *
What is student's T-shirt size? *
Name of Parent(s) or Guardian(s) *
Your answer
Home Phone Number *
Your answer
Mother's Cell Phone Number *
Your answer
Mother's Work Phone Number *
Your answer
Father's Cell Phone Number *
Your answer
Father's Work Phone Number *
Your answer
Street Address / Mailing Address *
(Post Office Box addresses are not acceptable. Please include Zip Code.)
Your answer
E-Mail Address *
Confirmation of receipt of application will be sent by e-mail so please indicate one you use frequently.
Your answer
If you have an Emergency Contact other than a Parent or Guardian
Provide Name, Phone number, and Relationship to Student
Your answer
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