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2. Student Information
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Email Address*
16. School Name (2023/24 School Year)*
17. Grade (2023/24 School Year)*
19. I have reviewed the program schedule and can attend all sessions.*
    -- Select One --YesNo
20. I understand that the 34 hours of service credits includes 12 hours of work outside of class to complete program assignments.*
    -- Select One --YesNo
22. Lunch will be provided to registered students. Please describe any dietary restrictions.*
24. Please describe your interest in this program, including knowledge and experiences that you hope to gain.*
26. Please describe the activities you participated in during the current school year and plan to participate in during the upcoming school year.
28. Parent/Guardian Information
30. First Name*
31. Last Name*
33. Address*
35. City*
36. State*
37. Zip Code*
39. Phone Number*
40. Email Address*
42. Emergency Contact (if different than Parent/Guardian above)
44. First Name
45. Last Name
47. Phone Number
48. Email Address
50. Relationship to Student
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field