* Required Field

 

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* 1. Last Name:

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* 2. First Name:

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* 3. Preferred Name:

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* 4. Gender:

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* 6. Date of Birth:

Date

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* 7. Place of Birth (City, State):

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* 8. Please share who referred you to REACH Memphis.

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* 9. Please provide the name, email address, and/or phone number of the person who referred you.

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* 10. School Name:

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* 11. Grade:

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* 12. School Guidance Counselor's Name

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* 13. Student Address:

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* 14. City:

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* 15. State:

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* 16. Zip Code:

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* 17. Home Phone:

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* 18. Your Cell Phone:

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* 19. Your Email Address:

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* 20. What student leadership positions have you held?

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* 21. What special recognitions have you received?

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* 22. Have you had a previous summer experience at a prep school, college, or leadership program?

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* 23. If the answer to #22 is Yes, where have you gone?

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* 24. Have you participated in a virtual summer experience?

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* 25. If the answer to #24 is Yes, what type of virtual program did you participate in and what school offered the visual program?

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* 26. What are your career aspirations?

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* 27. What extracurricular activities do you participate in?

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* 28. What are your special talents or skills?  (e.g., singing, playing an instrument, acting, drawing)

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* 29. What are your hobbies?

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* 30. Please indicate the sports in which you participate (check all that apply).

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* 31. Is there a day of the week that you CANNOT participate in a REACH Memphis virtual session? (Please list the day.)

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* 32. If accepted, will you agree to participate in bi-monthly virtual sessions?

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* 33. Is there a primary language, other than English, spoken in your home?

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* 34. If the answer to #33 is Yes, what is the name of the language?

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* 35. What foreign languages, if any, are you studying at school?

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* 36. Will you be the first person in your family to attend college?

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* 37. If the answer to #36 is No, who in your family attended college? (Click all that apply)

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* 38. Who in your family has graduated from college? (Click all that apply)

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* 39. Is anyone in your family a REACH Memphis (formerly Memphis PREP) alumnus? If so, please provide maiden name and current name.

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* 40. What organizations do you belong to outside of school?

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* 41. With whom do you live?

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* 42. Name of Parent or Guardian 1:

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* 43. Relationship to Applicant:

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* 44. Occupation:

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* 45. Employer:

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* 46. Work Phone:

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* 47. Home Phone:

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* 48. Cell Phone:

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* 49. Email Address:

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* 50. Name of Parent or Guardian 2:

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* 51. Relationship to Applicant:

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* 52. Occupation:

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* 53. Employer:

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* 54. Work Phone:

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* 55. Home Phone:

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* 56. Cell Phone:

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* 57. Email Address:

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* 58. Emergency Contact Name:

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* 59. Emergency Contact Phone:

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* 60. How many people are in your household?

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* 62. ESSAY
Cut and paste 350-  to 500-word essay into this essay template. 

Describe a challenge you have faced and how it impacted you.  What did you learn?  How do you view yourself because of it?

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