To register to attend, please complete the form below.

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* 1. Currently registration for Senior Summit is at capacity and you are registering for the wait-list. Wait-listed students MUST complete the student packet and sign up to attend a mandatory orientation (see question 15 on this survey) in order to be considered for the event.

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* 2. Student's First Name:

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* 3. Student's Last Name:

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* 4. Student's High School/Community Organization:

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* 5. Student's date of birth:

Date

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* 6. Student's E-mail Address:

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* 7. Student's High School Graduation Year:

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* 8. What is your current A-G Grade Point Average (GPA)?

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* 9. Do you plan on attending a 4-year college/university in the Fall 2017?

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* 10. Do you plan on attending a community college in the Fall of 2017?

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* 11. Student's home phone number:

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* 12. If available, student's cell phone number:

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* 13. What is the ethnicity of the student?

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* 14. Do you (the student) need special accommodations due to a disability?

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* 15. Mandatory Orientation:
To be certain that all parents receive crucial information about the Senior Summit, UCR campus, and rules and regulations, parents/legal guardians and Senior Summit participants must attend ONE of the orientations.

Please select the orientation the student and at least one parent/guardian will attend:

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* 16. Personal Insight Questions:
To maximize the time spent at the program, all students wishing to attend Senior Summit must complete 4 of the UC Personal Insight Questions and bring their responses to the orientation date selected above. A Personal Insight Guide will be included in the Student Packet.

Failure to submit the completed questions will forfeit your seat at Senior Summit for a student on the wait list.

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* 17. After clicking the submit button you will be redirected to the Senior Summit student packet. To participate in the event, students must return the waivers to the EAOP office via e-mail, fax, mail, or drop off by the June 3, 2016 deadline.

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