I. GENERAL INFORMATION

First Name
Last Name
Age
Birth date (mm/dd/yyyy)
Student's E-Mail
Home Street Address
Apt.
City
State
Zip Code
Home Phone
Student's Mobile Phone

Gender Male Female

Ethnicity:

African American	Native American	Asian
Caucasian	Pacific Islander	Multiracial/Multiethnic
Hispanic/Latino	Other

Is the student eligible for reduced-cost/free lunch program at school? YES NO

Name of Parent/Legal Guardian #1:
Daytime Phone:
Mobile Phone:
Email:

Name of Parent/Legal Guardian #2:
Daytime Phone:
Mobile Phone:
Email:

ACADEMIC INFORMATION

Current Grade Level:
Name of School You are Attending:
Street Address:
City: State: Zip:

Name of Teacher, Counselor, or Principal who can nominate you to participate in Innoworks:
Position:
Phone Number:
Email:

PLEASE ANSWER THE FOLLOWING QUESTIONS

1.) Why would you like to enroll in Innoworks? What do you hope to gain from participating in the program?

2.) Are you interested in science, technology or engineering? If so why? If not, why not?

3.) How do you see yourself contributing to the future development of your local community?

4.) Have you participated in other science, technology, engineering, and/or mathematics enrichment
programs before? If so, please list and describe your experience(s).

5.) (Optional) Please include anything else about yourself that you would like us to know.

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