Student Application

Applicant Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Student Cell Phone

Email*

Birth Date

MM

DD

YYYY

Gender*

Male
Female

Ethnicity

Snapchat Username

Twitter Handle

Primary Language spoken at home

Primary source of transportation

Name*

Parent/Guardian

First Last

Home Phone*

Work Phone*

Cell Phone*

Email*

Annual Household Income?

School Name*

Current Grade Level*

List Subjects*

Extracurricular Activities*

Position Held/Honors*

Hobbies/Interests*

Inventions/Projects*

List your favorite tech devices*

Counselor/ Teacher Name*

First Last

Teacher Phone*

Email*

What do you want to learn at S.U.P.A. S.T.E.A.M.?*

What do you want to accomplish at S.U.P.A. S.T.E.A.M.?*

What do you want to tell about yourself?*

Check the words that best describe you:*

Is there anything else you would like to add?

(File examples: videos, letters, or artwork.) [Max file size 25MB]*

Drop files here or

Do you have any health concerns or allergies?*

Yes
No

If yes, please explain*

What do you want to tell us about your family background?*

Emergency Contact Name

First Last

Relationship

Phone

S.U.P.A. Inc. Supporting UnderPrivileged Americans is dedicated to equal opportunity education.

By typing your name below, and submitting this application I hereby authorize that all the above information is true and accurate. I give permission to release any photos in order for them to be used for program marketing material. I release S.U.P.A. S.T.E.A.M. Academy and individuals from liability in case of accident during activities related to the program.

Type Student Name (Signature)*

Date*

MM

DD

YYYY

Type Parent/Guardian Name (Signature)*

Date*

MM

DD

YYYY

S.U.P.A. Inc.

Supporting UnderPrivileged Americans

S.T.E.A.M. Academy

• Science • Technology • Engineering • Arts • Mathematics