1.What is your first and last name?

2.Are you a junior or senior?

Junior

Senior

3.What school do you attend?

4.Parent(s) name(s)

5.Parent(s) telephone number

6.Parent(s) email address

7.Student's telephone number

8.Student's email address

9.Will you need transportation assistance?

Yes

No

10.Would you like to be contacted by a Career Specialist for potential summer work experience?

Yes

No