NSSA Student Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Ethnicity (Check all that apply)

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Elementary School, Middle School or High School
What grade are you?
Did one or both of your parents graduate from a four-year college or university?
Nature STEAM SMART Academy Application Questionnaire
What interests you most about learning? (Maximum of 300 words.)
Discuss why you would like to attend The Nature STEAM Smart Academy Program and how you think it will benefit you? (Maximum of 300 words)
Is there anything else that you would like to highlight about yourself? (Optional)
Students who demonstrate financial need can apply for a program registration scholarship. Are you interested in learning more?
How did you hear about The Nature STEAM Smart Academy Program?

Other
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number

Area CodePhone Number
Parent/Guardian Email address
example@example.com
Should be Empty: