ETS Middle School Summer Academy 2023
Please answer all questions.
Student Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Cell Number
*
Please enter a valid phone number.
Student Personal Email
*
example@example.com
Student Birthdate
*
Ethnicity/Race
*
1- American Indiana or Alaska Native, Non-Hispanic/Latino
2- Asian, Non-Hispanic/Latino
3- Black or African American, Non-Hispanic/Latino
4- Hispanic/Latino of any race
5- Native Hawiian or other Pacific Islander, Non-Hispanic/Latino
6- Two or more races. Non-Hispanic/Latino
7- White, Non-Hispanic/Latino
Gender Assigned at Birth
*
Male
Female
What do you identify as?
Age
*
Name of School
*
Scranton
Wade Park
Other
Name of School (other)
*
Are you a U.S. Citizen?
*
Yes
No
Permanent Resident (Green Card)
Grade in 2023 - 2024
*
6th
7th
8th
Graduation Year
*
Do you have any allergies or dietary restrictions?
*
Who do you live with?
*
Both Parents
Mother
Father
Both Grandparents
Grandmother
Grandfather
Other Relative
Non-Relative
Independent
Foster Care
Other
Living with (other)?
T-Shirt Size
*
S
M
L
XL
2XL
3XL
Parent/Guardian Name
*
First Name
Last Name
Relationship
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
MOTHER's highest level of education completed
*
Less than 9th-grade
High School Diploma
Associate's Degree (2-years)
Bachelor's Degree (4-years)
Master's Degree
Doctorate
FATHER's highest level of education completed
*
Less than 9th-grade
High School Diploma
Associate's Degree (2-years)
Bachelor's Degree (4-years)
Master's Degree
Doctorate
Alternate/Emergency Contact
*
First Name
Last Name
Alternate/Emergency Contact Relationship
*
Phone Number
*
Please enter a valid phone number.
Student Signature
*
Powered by
Jotform Sign
Clear
If already a participant in ETS, UB or UBMS, do not complete Income
Number of Adults in Household
Number of Children in Household
Family Income Level
$0 - $19,320
$19,321 - $26,130
$26,131 - $32,940
$32,941 - $39,750
$39,751 - $46,560
$46,561 - $53,370
$53,371 - $60,180
$60,181 - $66,990
$66,991 - Over
Parent Signature
Powered by
Jotform Sign
Clear
Submit
Submit
Should be Empty: