Project Exploration Student Intake Form
Basic Student Application
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Email *
STUDENT INFORMATION
First Name *
Middle Initial *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Gender *
Required
Ethnicity (check all that apply) *
Required
What is the primary language spoken at home? *
What is the best way to reach you (student)? (Check all that apply) *
Required
Please provide profile name (Facebook or Instagram) or Twitter handle. *
Cell Phone Number *
Home Phone Number *
Email Address *
CURRENT SCHOOL INFORMATION
School Name *
Grade *
Expected Graduation Year *
My child listed above has permission to participate in the Project Exploration program. *
I give permission to release my child's grades for evaluation purposes? Note: Data would be anonymous. *
Parent/Guardian Signature *
EMERGENCY CONTACT INFORMATION
Parent/Guardian Name *
Home Phone Number *
Cell Phone Number *
Email Address *
Additional Emergency Contact Name
Name *
Relationship to Student *
Home Phone Number *
Cell Phone Number *
Does your child have any allergies or medical conditions? (e.g. animals, penicillin, asthma, seizures)? *
If yes, please list. *
How would you like Project Exploration to respond if something happens? *
A copy of your responses will be emailed to the address you provided.
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