Project Discovery Online Application

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* 1. Student Name (first and last)

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* 2. Student Social Security Number

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* 3. Student Contact info

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 4. Student Date of Birth (month/day/year)

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* 5. Gender

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* 6. Race

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 7. Ethnicity

Hispanic

Non Hispanic

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* 8. Disability

Disabled

Not Disabled

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* 9. School

William Fleming

Patrick Henry

Northside

Covington HS

Allegheny HS

Eastern Montgomery

Other (please specify)

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* 10. Grade

Other (please specify)

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* 11. If applicable: Free or reduced lunch

Yes

Does not apply

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* 12. Did your mother graduate from a 2 or 4 year college in the US

Yes

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* 13. Did your Father graduate from a 2 or 4 year University

Yes

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* 14. Emergency Contact info (parent or guardian)

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number