SUCCEED: Workshops Application

Workshops Application

Workshops:

Select all workshops you are applying for:

Select All - Select None

Student's first name:

Student's last name:

Student's gender:

Not required - for statistical purposes only

Male

Female

Select None

Student's ethnicity:

Not required - for statistical purposes only

Select None

Student's age:

Student's grade:

If you are a home school student, estimate an approximate grade level

School name:

School type:

public

private

home school

other

Please include any medical issues that we may need to know:

Parent or Guardian information:

Parent's first name:

Parent's last name:

Street address:

Street address, second line:

City:

State:

Zipcode:

County:

Parent's email address:

Please use an email you check regularly.

Confirm Email:

Daytime phone number:

example: 919-999-9999

Evening phone number:

same format as above

Additional Information:

How did you find out about the SUCCEED workshops?

Briefly describe your experiences in science and mathematics (classes, self-study, extracurricular programs, summer activities, etc.). What do you like most about science or mathematics?

Briefly describe why you wish to participate in this program and what you hope to accomplish:

Additional comments or questions:

	Yes	No
Will you be requesting financial aid?			*
Would you like to be added to the Shodor mailing list?			*

Select None

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