California Student Application Form

Student Application
Student Contact Information
Student Name*

First NameLast Name
Grade Level*

6th grade7th grade8th grade
T-Shirt Size (please note t-shirts are adults sizes)*

X-SmallSmallMediumLargeX-Large
Parent/Guardian Contact Information
Parent/Guardian Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred method of contact:*

CallTextEmail
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?*

YESNO
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?*

ExcitedNervousCurious
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