Healthy Brain Scholars Program for Youth
Student Name
*
First Name
Middle Name
Last Name
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
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Day
2023
2022
2021
2020
2019
2018
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2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
Student E-mail
*
example@example.com
Student Mobile Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of High School
*
Current student's grade (School year 2023-2024)
*
Have you taken SAT or ACT? If YES, please submit a copy of your score.
*
Please Select
Yes
No
Copy SAT or ACT score
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Please upload an unofficial copy of your current transcript.
*
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Please upload a response to the following prompt: 300-500 words. As a student and an individual, reflect on what education means to you. How will a college education impact who you are? How do you plan to use your education in the future?
*
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Parent Information Questions
Father's Full Name
First Name
Last Name
Mother's Full Name
First Name
Last Name
Parent's Email
*
example@example.com
Parent's Phone
*
Please enter a valid phone number.
What is your father's occupation?
What is your mother's occupation?
Please answer the following household questions
How many college students are in your household currently?
*
Number of dependents in your household.
*
What is the status of your housing?
*
Please Select
Rent
Own
How much is your monthly housing rent or mortgage?
*
Please upload the following documents.
1. 2022 Income tax return (Form 1040) 2. W-2 (Year 2022) 3. Schedule C-Profit or Loss from Business or Form 1120 if applicable
Upload 2022 Parent Income Tax Return (Form 1040)
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Upload Parent W-2 (Year 2022)
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Upload Schedule C-Profit or Loss from Business or Form 1120
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(If parent owns a business)
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Additional Comments
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