MESA 2024-2025
Student Enrollment Form
Welcome to MESA!
An enrollment form is required for any student participating in MESA. A completed enrollment for is required for any student to attend MESA Day on May 16th, 2025. Please reach out to your MESA Chapter Advisor or ormesa@pdx.edu if you have any questions!
Student Information
Legal Name (first and last name)
*
(Ex: Julio Martinez)
Preferred Name or Nickname
(Ex: Julio)
24-25: Preferred Pronouns (select all that apply)
*
She/Her
He/Him
They/Them
Prefer not to answer
Other
24-25: Gender
*
Please Select
Girl/Woman
Boy/Man
Non-binary
Questioning/Unsure
Trans Man
Trans Woman
Identity or Identities Not Listed
Prefer Not To Answer
24-25: Non-School Email
*
24-25: Phone Number
*
24-25: Address
*
Address
City, State
Zipcode
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
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16
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31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
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1999
1998
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1996
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1989
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1981
1980
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Oregon Student ID Number
*
If unknown, please ask your teacher as it is required or put NA (DO NOT PUT 0)
24-25: T-Shirt Size
*
Please Select
XS
S
M
L
XL
2XL
3XL
Note that these are adult sizes, not youth.
24-25: Current Grade
*
Please Select
4
5
6
7
8
9
10
11
12
24-25: Anticipated High School Graduation Year
*
Please Select
2025
2026
2027
2028
2029
2030
2031
2032
2033
24-25: MESA Chapter
*
Please Select
Alder Creek Middle School
Beaverton High School
Bonanza Jr/Sr High School
Brixner Junior High School
Cascade Middle School
Centennial High School
Chemawa Indian School (Bureau of Indian Education)
Chiloquin Jr/Sr High School
De La Salle North Catholic High School
Early College/Roberts High School
Echo Shaw Elementary School
Faubion PK-8 School
George Middle School
Hacienda CDC
Hamlin Middle School
Henley High School
Kellogg Middle School
Klamath Union High School
Lewelling Elementary School
Liberty High School
Lincoln Middle School
Mazama High School
McDaniel High School
McKay High School
North Marion Middle School
North Medford High School
North Salem High School
Ockley Green Middle School
Parkrose High School
Parkrose Middle School
Ponderosa Middle School
Poynter Middle School
Putnam High School
Reynolds High School
Reynolds Middle School
Roosevelt High School
Rosemary Anderson High School North Campus
Rosemary Anderson High School New Columbia
Roseway Heights Middle School
Spark by Connected Lane County (Eugene)
Spark by Connected Lane County (Springfield)
Swegle Elementary School
Waldo Middle School
Whiteaker Middle School
Whitford Middle School
Woodlawn Elementary
This is your school or club's name.
24-25: Race/Ethnicity (select all that apply)
*
Black or African American
Asian
Caucasian or White
Hispanic or Latina/o/e
Native American/Indigenous/Alaska Native
Native Hawaiian or Other Pacific Islander
Middle Eastern/Northern African
Do not wish to report
Other
24-25: What would you like to study in college?
Computer Science
Engineering
Math
Science
Health
Vocational School
Business, Law, or Social Sciences
Unsure
Other
24-25: What year did you join MESA?
*
(Ex: 2024)
24-25: Do you have any Allergies/Dietary Restrictions?
24-25: Do you have any accommodation/accessibility needs?
Do you require any accommodation, mobility or translation assistance to participate in MESA Events outside of chapter meetings? If yes, please specify what those are.
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Emergency Contact Information
Contact Name
*
First Name
Last Name
EC: Relation to Student
*
Please Select
Mother
Father
Step-Mother
Step-Father
Parent
Aunt
Uncle
Grandmother
Grandfather
Guardian
Elder Sister
Elder Brother
EC: Cell Phone
*
EC: Email
*
Occupation/Trade
24-25: Please select the most advanced level of education in the household:
*
Please Select
Ph.D./M.D.
Master's Degree
Bachelor's Degree
Associate's Degree
Vocational/Technical Degree
Some College
High School Diploma/GED
Middle School
Unsure/Other
EC: Preferred Language 1
*
EC: Preferred Language 2
24-25: Do you need translation for any of your preferred languages?
*
Please Select
Yes
No
24-25: Is your student eligible for Free or Reduced Lunch?
*
Please Select
Yes
No
Unsure
24-25: How would you prefer to receive MESA Event notifications?
*
Please Select
Text
Email
Both
No Thank You
Photo Release
Oregon MESA occasionally uses students' likeness, video recording, or audio-recording of their voice in MESA promotional materials such as newsletters, brochures and websites. Please mark whether you give MESA consent to use your child's likeness in promotional materials:
24-25: Photo Release Consent
*
Please Select
Yes I give permission
No I do not give permission
If you have any questions or concerns about photo release, please contact Michela Sottura at msottura@pdx.edu
Parental Consent
For any student to be allowed to participate in MESA and attend MESA Day in May, the Parent/Guardian of the student must review our application waiver attached (you can use the zoom & full screen buttons to expand, and feel free to download for your own records). Once you have reviewed those statements, please sign below to signify that you consent to the waiver.
24-25: Parent/Guardian Signature
*
Voluntary Survey
MESA is working with Education Northwest, a non-profit education research and technical assistance organization in Portland, to learn more about students’ MESA experience this year. Please read the document below. If you have questions about this focus group, please contact Pablo López Trujillo at p.lopeztrujillo@ednw.org | 503-275-9627.
Please review the waiver attached (you can use the zoom & full screen buttons to expand, and feel free to download for your own records).
If you agree to let your student participate, please indicate which evaluation activities they can participate in:
*
Yes, I agree to let my student participate in a MESA focus group.
Yes, I agree to let my student participate in a MESA survey.
No, I do not agree.
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