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Name of Applicant
Address where applicant receives mail
Date of Birth (month/day/year)
Age applicant will be at MetroTown
School you will be attending Fall 2017
Grade you will be enrolled in Fall 2017
Parent or Guardian Name(s):
Primary Parent/Guardian Mailing Address (if different from applicant’s address ):
Parent’s/Guardian’s Phone (Home)
Parent’s/Guardian’s Phone (Work)
Parent’s/Guardian’s Phone (Cell)
Does parent/guardian speak English?
Primary Parent’s/Guardian’s E - Mail Address:
What is the language spoken in the home?
Preferred way to contact parent (select one)
Ethnic/Cultural Background (if selected "Other", please specify)
American Indian/Indigenous American
Faith Or Religious Affiliation
Faith or Religious Affiliation (if selected "Other", please specify):
Household Arrangement (if selected "Other", please specify):
School Lunch Program
Sexual Orientation (if selected "self-identified", please specify)
Special Needs: Does the applicant have a disability?
Special Needs: If yes, what accommodations/modification are required?
Special Needs: Does applicant have any special needs?
If applicant has any special needs, please explain:
Are you a Student Voices Panelist? If yes, when were you trained?
Are you a member of any other school clubs or participate in any school activities or sports? If yes, what clubs/activities/sports? (Include for how long and role/ position)*
In what other capacities are you involved in your community? (job, religious, political, arts, music, neighborhood, service, etc.)*
Please describe a time when you have experienced or witnessed prejudice, discrimination, or some other “ism” (for example: racism, sexism, ageism, etc.). Provide details including how you felt, what you saw, what you did, and how that event made you see yourself or others in a new light.
Please tell us about a time when you have taken some sort of action to stop prejudice, discrimination, or some other form of “ism.” If you have not taken an action, describe a time when you wish you had taken an action and why you did not.
What would you like to get out of your MetroTown experience?
Please talk about one or two social issues that interest you or you want to know more about. Describe the issue, and tell us why it matters to you. If applicable, also tell us what you have done so far to learn more about it and/or take action to make change.