Program Interest Selection Form
To register, please fill out the form carefully. Once the selected programs have started, you will be contacted via email.
Participant Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal E-mail
*
example@example.com
School E-mail
*
example@example.com
Cell Number
*
Format: (000) 000-0000.
Your grade
*
What school are you attending?
*
How did you hear about our programs?
*
Please Select
School
Church
Friend
Facebook
Instagram
Twitter
Word of Mouth
Visiting Our Site
Other
Interested Program(s) - Rank your top three choices using 1, 2 and 3
*
Rows
First Choice
Second Choice
Third Choice
Aspiring Aviation or Aerospace Enthusiast
College and Scholarship Advisement
Google Certificate Scholarship
Healthy Eating Alternatives
Financial Wellness Workshop (including trading stocks, options; crypto)
Etiquette Workshop/Modeling Boot Camp
Academic Support/Tutoring
Technology Enrichment Program
Life-skills Development
English Language Learning
Parent/Guardian Name
*
First Name
Last Name
Cell Number
*
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Additional Comments
Signature
Submit Application
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