HBS Program Application

Healthy Brain Scholars Program for Youth
Student Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender *
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 2021-2022) *
Have you taken SAT or ACT? If YES, please submit a copy of your score. *
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? *
How much is your monthly housing rent or mortgage? *
Please upload the following documents.

1. 2021 Income tax return (Form 1040) 2. W-2 (Year 2021) 3. Schedule C-Profit or Loss from Business or Form 1120 if applicable
Upload 2021 Parent Income Tax Return (Form 1040)

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Upload Parent W-2 (Year 2021)

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Upload Schedule C-Profit or Loss from Business or Form 1120

(If parent owns a business)
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Additional Comments
Please click save if you want to submit it later.

Thank you for submitting your application! The notification date will on July 15, 2022
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Healthy Brain Scholars Program for Youth

Parent Information Questions

Please answer the following household questions

Please upload the following documents.

Please click save if you want to submit it later.