MIGIZI Green Tech Waiting List Form
Fall 2023
MIGIZI uses this form for basic contact and demographic information.
Program
*
Please Select
Green Tech Internship
Choose which program you wish to enroll in.
Student Name
*
First Name
Last Name
Student Phone
If applicable.
Student Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
/
Month
/
Day
Year
Reservation/Tribal Affiliation(s)
If applicable.
Are you tribally enrolled?
*
Please Select
Yes
No
Unsure
Which of the following best describes you?
*
Hispanic or Latino or Spanish Origin of any race
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Two or more races
School
*
Write in your school name if applicable. If not, input N/A.
Grade
*
If applicable. If not, input N/A
Are you behind on any credits in school?
Yes
No
Student ID
Write in your student ID if applicable.
Health Concerns, Allergies, etc.
*
If nothing, input N/A
Highest level of education attended
*
Please Select
Still in high school
High school diploma
GED
None of the above
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Where did you find out about MIGIZI or who told you about MIGIZI?
*
Parent/Guardian Signature
Clear
Student Signature
Clear
Submit
Should be Empty: