Exit this survey PPIA Pre-Arrival Survey 2018 1. Default Section Question Title * 1. Complete the contact information listed below. Use the address where you would like the stipend mailed. The stipend will be mailed in early June. First Name & Middle Initial: * Last Name: Address (where to mail your stipend): * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * school email address: * personal email address: * Summer Phone Number: * Question Title * 2. List emergency contact information for a parent, guardian, or other relative we can contact in case of an emergency. Emergency Contact Name: Relationship to you: Phone Number: Question Title * 3. Will you be bringing a laptop with you for the summer? Yes No Don't know yet Question Title * 4. Do you have any special needs including, but not limited to, religious observations, learning disabilities, hearing or vision impairments, or any other physical challenges for which we must make advance arrangements? Question Title * 5. Do you have any special dietary needs such as keeping kosher, vegan or vegetarian meals, etc? Next
