Name:
Email:
Address:
City:
Zip:
Date of Birth:
Gender: M: F:
Current School:
Current Grade:
Expected Date of Graduation: June 20
Current Average:
Parent/Guardian Name:
Parent Phone Number: Type: Home Work Cell
Are you a U.S. Citizen or Permanent Resident: YesNo
If No, Country of Citizenship:
Did either of your parent(s)/guardian(s) attend college?: YesNo
Does either of your parent(s)/guardian(s) have a bachelor's degree?: YesNo
Are you currently involved in any after-school sports or activities?: YesNo
Are you enrolled in any other pre-college enrichment program?: YesNo
What do you plan to do after you graduate from high school?:
Briefly explain why you want to participate in this program?
Are you currently under a physician's care for treatment regarding an illness you have, do you have asthma, do you have a learning disability of any kind, are you currently taking medication, and/or do you have diabetes, etc? YesNo


Please describe your situation below.