American Student Assistance/Dana-Farber Career Exploration Program Application

1. GENERAL INFORMATION

The Career Exploration Program offers 8 educational workshops, including one college tour, on Wednesday afternoons at Dana-Farber Cancer Institute from January 22 to April 15, 2020. Students who successfully complete the program (100% attendance) will receive a $250 gift card and qualify for the Summer Jobs Program at Dana-Farber.

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* 1. PERSONAL INFORMATION

Name:

Date of Birth:

Age:

Street Address:

City:

State:

Zip Code:

Email:

Cell Phone:

Home Phone:

School:

Year of Graduation:

BSP ID Number:

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* 2. EMERGENCY CONTACT 1

Name:

Email:

Phone:

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* 3. EMERGENCY CONTACT 2

Name:

Email:

Phone: