Motivation Conference  Registration  2014
Motivation Conference (MC) is a student-initiated outreach program created by the Asian Pacific Islander Student Alliance (APISA) and housed within Engaging Education.

The information collected here will only be used for the evaluation purposes of MC and Engaging Education. Your information will not be distributed/shared for any other purposes and will be kept private. Answers collected here will be used for identifying students most in need of this conference. To be considered for this program you must complete all questions.

Completion of the form does not guarantee admission into the program. You will be contacted via email and phone for confirmation of acceptance into the MC program.

The deadline to complete the application form is  TUESDAY, April 15, 2014 at 11:59pm.


**Submitting the registration form does not guarantee admission into the program. You will receive a confirmation email and/or phone call with further details. Please be aware that space is limited so students will be selected based on program criteria.  Program pick up and drop offs will be in Norcal. Stops are TBD.
Sign in to Google to save your progress. Learn more
Type of Participant *
First Name *
M.I. *
Last Name *
Date of Birth *
Format: MM/DD/YYYY
Address *
Example: 123 Engaging Education St Apt. #1
City *
State
Zip Code *
E-mail Address *
Home phone number
Format : ### ### ####
Cell phone number *
Format: ###-###-####
Gender *
Name of School or Community Center *
Zip Code of School or Community Center *
Grade Level *
Graduation Year *
(Expected High School Graduation)
GPA *
Example: 3.0
Ethnicity *
Indicate all that apply. If you identify as Pacific Islander, please write in other if you would like to be specific.
Required
Dietary Needs *
Shirt Size
Clear selection
Guardian/Parent 1 Educational Level *
Mark the highest level of education completed by Guardian 1
Guardian/Parent 2 Educational Level *
Mark the highest level of education completed by Guardian 2
Estimated Family Income *
Future Plans *
I would like more information on...
Indicate all that apply
Do you need any special accommodations? *
Do you have allergies?
please list them below
Are you able to walk for 40 minutes *
Tell us a little about yourself *
Hobbies, talents, interests, jobs..etc
Tell us about your experiences with school and withing the education system. *
What are you plans after high school? Do you plan to pursue higher education? Why or why not? *
How do you feel being an API (Asian and/or Pacific Islander)/individual of color? Has there been an instance/experience where you felt you were treated differently because of it? *
Are you a first generation college student?
Clear selection
Have you ever been to Motivation Conference before? *
Why do you want to go to Motivation Conference? What do you hope to gain from this experience? *
Parent/Guardian Name
Parent/Guardian Cell number
format: ### ### ####
Emergency Contact Name
Emergency Contact number
Emergency contact relationship
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms