California Student Application Form

Student Application
Student Contact Information
Student Name

First NameLast Name
Grade Level
T-Shirt Size (please note t-shirts are adults sizes)
Parent/Guardian Contact Information
Parent/Guardian Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred method of contact:
Math Teacher Contact Information
School
Math Teacher's Name

First NameLast Name
E-mail
example@example.com
Tell us a bit more about yourself
Have you applied for a CA Shine for Girls session before?
Have you participated in a previous CA Shine for Girls session before? If so, what session (IE- Fall 2016)
Why do you want to participate in SHINE?
What were your grades in math last school year?
What other extracurricular activities are you involved in?
How are you feeling about the SHINE program?
Do you have access to a computer/laptop and WiFi to connect to our virtual SHINE sessions?
Do you know anyone else who is applying? If so, please list their names.
How did you hear about SHINE?
Is there anything else we need to know?
Signature
That's it! By digitally signing below, you confirm that you are a middle school girl living in in the Kern County area.
Signature
Signature date
Should be Empty:

Student Application