Missouri City NSBE JR explorers Registration Form
Complete this form to join Missouri City NSBE Jr Explorers - also see https://nsbe.org/pci/ for additional details about our pre-collegiate (PCI-chapter). Annual membership dues is $35 (of which $7 national dues) covers the calendar period August 1 - July 31 and does not include costs to attend regional or national conventions.
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Student Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Student Email
*
example@example.com NOTE: each student must have a unique email address
Student Race
*
Please Select
African
African American
Asian American
Canadian American
Central American
Mexican American
South American
European American
Latino
*
Please Select
Yes
No
Parent/guardian Information
Parent(s)/Guardian(s) Name 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com; if possible, a gmail account preferred
Parent(s)/Guardian(s) Name 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
example@example.com; if possible, a gmail account preferred
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
student Education Information
Student Grade Level
*
Please Select
6
7
8
9
10
11
12
Name of School Attending
*
Name of School District
*
If Home School or Private; indicate location (City and State)
List any particular fields of STEM interested in studying and any/or any hobbies?
Contact In case of Emergency
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Relationship
*
Submit
Should be Empty: