STUDENT APPLICATION STUDENT APPLICATION Name * Required First Middle Last Date of Birth - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Gender * RequiredMaleFemaleAddressHome Telephone Number * RequiredStudent Cellular Phone NumberStudent E-mail * Required Parent/Guardian E-mail * Required Do you have any mental, physical and/or learning disabilities? * RequiredYesNoIf yes, please explain:Ethnic-racial background * RequiredNative American IndianAfrican AmericanHispanicAsian AmericanWhite/CaucasianOther(specify)Is the participant eligible to apply for financial aid? * RequiredYesNoHigh School Name * RequiredHigh School AddressCurrent Grade Level: * Required9101112Current G.P.A.: * RequiredMother’s Name: * Required First Middle Last Father’s Name * Required First Middle Last Legal Guardian’s Name: * Required First Middle Last Student lives with: * RequiredBoth ParentsFatherMotherStepmotherStepfatherLegal GuardianFoster HomeOther(Specify)Emergency Contact: * RequiredTelephone Number(s): * RequiredEmergency Contact’s Relationship to Participant: * RequiredSchool Counselor's Name * RequiredCounselor's Email * Required Teacher's Email * Required Student EssayIn the space below, write a brief essay stating your career interests, hobbies and goals, as well as why you are interested in participating in this program. This essay must be written by the student, without assistance from anyone (use only the space provided below). * RequiredApplicant's Name: * Required Date: - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.