Genius Labs Online Application

Student Name *

First

Last

Preferred Name and Pronouns *

Student Address *

Address Line 1

Address Line 2

City

State

Zip Code

Student Phone Number *

Email

Student Date of Birth *

MM/DD/YYYY

Parent / Legal Guardian Name *

First

Last

Parent / Legal Guardian Address (only if different from student address)

Address Line 1

Address Line 2

City

State

Zip Code

Parent / Legal Guardian Phone *

Parent / Legal Guardian Email

Where you referred to the program? If Yes, by who?

Name of School Student Attends *

City / District of School *

Age Student will be in during 22-23 school year *

Grade Student will be in during 22-23 school year *

Student Race (check all that apply) *

Question is for grant reporting and internal metric purposes only. Your specific personal information will not be shared outside of our organization.

Parent / Legal Guardian Race (check all that apply) *

Question is for grant reporting and internal metric purposes only. Your specific personal information will not be shared outside of our organization.

Student Vaccination Status *

*proof of full vaccination status required for youth to participate and parents/guardians/family members to attend the family meals.

Parent / Legal Guardian Vaccination Status *

*proof of full vaccination status required for youth to participate and parents/guardians/family members to attend the family meals.

Parent / Legal Guardian field of work or occupation *

*Why are we asking? Part of the future plans for this programming is to engage mentors, parents, and volunteers to provide career and vocational opportunities and activities with the youth.

Have you or your youth ever been considered a refugee from any country? *

Yes
No
Prefer not ot answer

Would you or your youth be considered an immigrant from any other country outside of the United States? *

Yes
No
Prefer not ot answer

Student Answer: Four words to describe you *

Student Answer: What are some of your favorite school-related activites? *

Student Answer: What are your favorite things outside of school (movies, music, books, etc.)? *

Student Answer: How important is technology in your day-to-day life? Why? Can you give examples? *

Student Answer: Select all of the following you use or own: *

Student Answer: If you selected "Other Technology", please list the technology you are referring to:

Student Answer: Tell us something else about yourself that you would like for us to know: *

Student Answer: Other comments, information, or message you'd like us to know about you? *

Genius Labs @ GMCC Digital Café

Online Application