Student's First Name: * Student's Last Name: * Student's Gender: * FemaleMale Student's Date of Birth (mm/dd/yyyy): * Student's Grade (K-12): * 1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeIn College Name of Student's School: * What interests you in the program?: * Has the student ever had a cognitive evaluation?: * SelectYesNo If yes, please provide a brief summary of reasons for testing and results: Does the student have any accessibility needs?: * SelectYesNo If yes, please describe the accessibility needs: Does the student have any learning difference(s)? (Choose all that apply): * NoneADHDHigh Functioning Autism/Asperger SyndromeLearning DisabilityOther (please explain in additional comments) Additional Comments: Street Address: * City: * State: * AKALAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Postal Code: * Parent/Guardian 1 First Name: * Parent/Guardian 1 Last Name: * Parent/Guardian 1 Relationship to Child: * MotherFatherStepmotherStepfatherAuntUncleGrandmotherGrandfatherFriend of FamilyOther Parent/Guardian 1 Email: * Parent/Guardian 1 Phone: * Parent/Guardian 2 First Name: Parent/Guardian 2 Last Name: Parent/Guardian 2 Relationship to Child: SelectMotherFatherStepmotherStepfatherAuntUncleGrandmotherGrandfatherFriend of FamilyOther Parent/Guardian 2 Email: Parent/Guardian 2 Phone: * These fields are required.