2025 Coach/Mentor Application

Summer Online Research Program:

Please indicate the session date(s) that you will be available (can choose more than one):

Session one: June 23 to July 11
Session two: July 14 to August 1

Personal Information

Last Name *		*required
First Name *		*required
Middle Initial
Date of Birth * (MM/DD/YYYY)		*required  Invalid Date format
Gender	Male Female Non-Binary
Ethnicity/Race	Hispanic or Latino American Indian or Alaskan Native Asian African American Native Hawaiian or Other Pacific Islander White/Caucasian Other (type)
Ethnicity Other	Please type in other ethnicity

Education

Name of College/University *		*required
College/University Address
Current Academic Level *		*required
Major
Current GPA  *		*required
Transcript may be required upon acceptance.

Contact Information

Home Address *		*required
City *		*required
State *		*required
Zip *		*required Invalid US Zip code
Email *		*required  Invalid Email Address
Home Phone		Invalid Phone Number
Cell Phone  *		*required Invalid Phone Format
Emergency Contact *		*required
Contact Phone * (555) 555-5555		*required  Invalid Phone Number
Parrent Name *		*required
Parent Street Address *		*required
Parent City *		*required
Parent Zip Code		Invalid US Zip code
Parent Phone Number * (555) 555-5555		*required  Invalid Phone Number
Parent e-mail		Invalid Email Address

* Please describe why you want to participate in this program (minimum of 750 characters, maximum 1200 characters or 150-200 words). Please type your document in Microsoft and copy and paste to this space:
Please describe why you want to participate in this program.