Microsoft-GECG 2019 Fall STEAM Mentorship Program Application Form

STUDENT FULL LEGAL NAME (exactly as printed on your passport or other government-issued ID)

Last/Family/Sur name(s) *

First/Given name(s) *

Middle name(s)

Preferred Name *

PRESENT MAILING ADDRESS

Street and Number *

City *

State/Province *

Zip/Postal Code *

CONTACT INFORMATION

Student Home Phone

Student Cell Phone

Student E-Mail Address *

Parent Last Name *

Parent First Name *

Parent Cell Phone *

Parent E-Mail Address *

SCHOOL ADDRESS

School Name *

CEEB Code

Street and Number

City

State/Province

Zip/Postal Code

Education

Some High School

High School Diploma

Date of Graduation

Date of Birth

Gender

Male

Female

Citizenship

US Citizen

US Permanent Resident

International student [ You must include Form HS-F with this application. Please fax to (404) 943-0015 ]

ETHNICITY (voluntary; US citizens and permanent residents only)

Do you consider yourself to be Hispanic/Latino?

Yes

No

In addition, please select one or more of the following racial categories to describe yourself:

Black or African American

American Indian or Alaskan native

Asian

Native Hawaiian or other Pacific Islander

White

Δ