STUDENT REGISTRATION

Student Name (full name) *

Email *

Cell phone Number *

Street Address (home) *

City, State, and ZipCode *

Emergency Contact

Date of Birth *

Gender

Dropdown *

Year in school (at date of application): *

College or High School currently attending: *

College you will be attending in the fall: *

Estimated college graduation date: *

Major or area of study:

Please list any specific technologies or technology related careers you would like to learn more about:

Please list any additional specific areas of interest:

How did you learn about this program:

Note: *Interns are responsible for their own transportation