Wired – Apply 2022 – Pacific American Foundation

Name*

First Last

I am applying as part of:*

Student's non-DOE email (personal gmail / not school issued)*

please do not use your K-12 school email address.

Enter Email Confirm Email

Phone Number*

A good phone number to reach you

SMS Text phone number*

The best number to use in case a text message is used in urgent situations.

Date of Birth*

Parent or Legal Guardian*

First Last

Parent or Legal Guardian Email*

Address*

Street Address City State ZIP Code

School Information

What school do you attend?*

Your Grade Level currently

Who is your science teacher or advisor?*

In the event of emergency, who would we be able to contact on your behalf?

Name of Emergency Contact #1*

First Last

Relationship*

Phone*

Mobile/Text Number if different from above

EMERGENCY CONTACT #2

optional

First Last

Relationship

Phone

Mobile/Text Number

I identify my gender as:

How do you identify your ethnicity (check all that apply)?

Do you receive Special Education Services?

Are you interested in a Science Career?

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Phone

This field is for validation purposes and should be left unchanged.