SUCCEED: Workshops Application

Workshops Application

Workshops:

select all workshops you are applying for

Apprenticeship Program Series Intro to Twenty First Century Skills

Apprenticeship Program Series System Modeling

Apprenticeship Program Series Agent Modeling

Apprenticeship Program Series System Administration

Apprenticeship Program Series Web Design

Apprenticeship Program Series Database Design and Intro to PHP

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:

Parent's email address:

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:

Will you be requesting financial aid?

Yes

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