Name of Applicant
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Email
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Home Phone
Cell Phone
Address where applicant receives mail
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City
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State
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
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Date of Birth (month/day/year)
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Age applicant will be at MetroTown
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School you will be attending Fall 2019
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Grade you will be enrolled in Fall 2019
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9th
10th
11th
12th
College/Military/Other
Parent or Guardian Name(s):
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Primary Parent/Guardian Mailing Address (if different from applicant’s address ):
Parent/Guardian City
Parent/Guardian State
Parent/Guardian Zipcode
Parent’s/Guardian’s Phone (Home)
Parent’s/Guardian’s Phone (Work)
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Parent’s/Guardian’s Phone (Cell)
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Primary Parent’s/Guardian’s E - Mail Address:
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What is the language spoken in the home?
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Preferred way to contact parent (select one)
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Email
Mail
Phone
Gender Identity
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Male
Female
Transgender
Gender Non-conforming
Ethnic/Cultural Backgrouind
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African
American Indian
Native American
Asian
Asian American
Caribbean Islander
Cuban
European
European American
Haitian
Jamaican
Jewish
Latino(a)/Hispanic
Middle Eastern
Pacific Islander
South Asian
Other
Ethnic/Cultural Background (if selected "Other", please specify)
Race
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Asian
American Indian/Indigenous American
Biracial/Multiracial
Black/African American
Caucasian/White
Other
Text
Faith Or Religious Affiliation
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Agnostic
Atheist
Buddhist
Catholic
Hindu
Jewish
Muslim
Protestant
Other
Faith or Religious Affiliation (if selected "Other", please specify):
Household Arrangement
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Both Parents
Single Parent
Other Relative
Other Non-relative
Other
Household Arrangement (if selected "Other", please specify):
Household Income
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$0-19,999
$20,000-49,000
$50,000-and up
Unknown
School Lunch Program
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Free
Reduced
N/A
Sexual Orientation
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Heterosexual/Straight
Bisexual
Gay
Lesbian
Pansexual
Questioning
Self-Identified
Sexual Orientation (if selected "self-identified", please specify)
Special Needs: If yes, what accommodations/modification are required?
If applicant has any special needs, please explain:
Are you a Student Voices Panelist? If yes, when were you trained?
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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)*
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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.
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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.
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What would you like to get out of your MetroTown experience?
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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.
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Submit