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Project Exploration Student Intake Form
Basic Student Application
* Required
STUDENT INFORMATION
First Name *
Your answer
Middle Initial *
Your answer
Last Name *
Your answer
Date of Birth *
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Age *
Your answer
Gender *
Required
Ethnicity (check all that apply) *
Required
What is the primary language spoken at home? *
Your answer
What is the best way to reach you (student)? (Check all that apply) *
Required
Please provide profile name (Facebook or Instagram) or Twitter handle. *
Your answer
Cell Phone Number *
Your answer
Home Phone Number *
Your answer
Email Address *
Your answer
CURRENT SCHOOL INFORMATION
School Name *
Your answer
Grade *
Your answer
Expected Graduation Year *
Your answer
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 *
Your answer
EMERGENCY CONTACT INFORMATION
Parent/Guardian Name *
Your answer
Home Phone Number *
Your answer
Cell Phone Number *
Your answer
Email Address *
Your answer
Additional Emergency Contact Name
Name *
Your answer
Relationship to Student *
Your answer
Home Phone Number *
Your answer
Cell Phone Number *
Your answer
Does your child have any allergies or medical conditions? (e.g. animals, penicillin, asthma, seizures)? *
If yes, please list. *
Your answer
How would you like Project Exploration to respond if something happens? *
Your answer
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