Form
INSPIRED MINDS
is a STEAM (Science, Technology, Engineering, Arts, and Math) program designed for 5th - 9th graders. The purpose is to broaden horizons through exposure to opportunities that lead to empowering experiences and successful careers. Once enrolled in the program, students remain connected through high school and beyond. Not only does this program provide mentorship, but also include activities such as financial literacy, music, robotics, fishing, filming, trips to college campuses, and so much more.
NOTE TO PARENT/GUARDIAN: This form is to be filled out WITH YOUR STUDENT
Student Information
First Name
Last Name
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
School
Add Your School name here
Grade
Add your Grade here
What's your favorite subject(s)?
What's your least favorite subject(s)?
Interests / Hobbies ?
What are your strengths?
What are some areas you desire to become better?
What do you expect from this program?
Do you have any food or other allergies?
Are you on any medications? If so, for what?
Have you ever been suspended from school? If so, check one
0-1
2-4
5 or more
Have you ever been arrested for (check all that apply)
weapons
sexual assault
violence
If you could be or do ANYTHING in the world, what would you do for a career?
Please Add Your First Choice, and Second choice
Who told you about this program?
Phone Number
Please enter a valid phone number.
Why do you think they told you about it?
Is there another person that recommended this program to you? If so....
Phone Number
Please enter a valid phone number.
Why do you think they told you about it?
PARENT/GUARDIAN
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
EMERGENCY CONTACT
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Submit
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