Applications will be accepted from
Monday, October 26, 2009 to Friday, November 20, 2009
Incomplete applications will result in automatic rejection from the program.
Applications must be rendered complete by the registration end date.
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All form fields are required, please mark feild with "N/A" if there is no response to field.
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| Last Name:
First Name:
Middle Name:
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| School Name
Grade Level
Age
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| Career Interest (1):
Career Interest (2):
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| Student Email:
Date of Birth
Gender:
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| Home Address:
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| City:
State:
Zip:
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| Student Home Phone:
Student Cell Phone:
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| Citizenship |
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please specify other country of citizenship
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Alien registration #
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| Language(s) spoken at home:
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Ethnicity (Please check all that apply)
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| Parent or Legal Guardian Name (1):
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| Home Phone:
Work Phone:
Cell Phone:
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| Parent or Legal Guardian Name (2):
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| Home Phone:
Work Phone:
Cell Phone
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| Does the student have transportation for summer internship/events?
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| How many people live in your household?
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What is your family’s income range?
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| Has this student ever been arrested?
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| If yes, was the student charged with a felony?
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| I agree that all of the information I provided is true and I understand that false information may result in expulsion from the P.O.P.S. program.
Initial this Statement:
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