SUCCEED

   

Workshops Application
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Workshops:
Select all workshops you are applying for:
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Student's first name:
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Student's last name:
Student's gender:
Not required - for statistical purposes only
Student's ethnicity:
Not required - for statistical purposes only
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Student's age:
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Student's grade:
If you are a home school student, estimate an approximate grade level
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School name:
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School type:
Please include any medical issues that we may need to know:
Parent or Guardian information:
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Parent's first name:
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Parent's last name:
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Street address:
Street address, second line:
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City:
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State:
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Zipcode:
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County:
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Parent's email address:
Please use an email you check regularly.
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Confirm Email:
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Daytime phone number:
example: 919-999-9999
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Evening phone number:
same format as above
Additional Information:
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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?
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Would you like to be added to the Shodor mailing list?
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