Public High School Student Registration

Student First Name:

Student Last Name:

Student email:

School:

Current Grade:

GPA:

Why are you interested:

please limit to 1000 characters

Parent Name:

Parent Telephone:

Parent Email:

Verify Parent Email:

Two Emergency Contacts:

1st contact	same as parent	or:	Name:	Tel:
2nd contact			Name:	Tel:

Fluent in:

English:

Spanish:

T-Shirt Size:

Small:

Medium:

Large:

Dear Parent:

Thank you for your interest in the Ignite Biotech Summer Program! By writing your email here:

you are consenting to your child’s participation in the 2019 Ignite Biotech Summer Program to he held at Colegio San Ignacio from June 3 to June 14.

In order to qualify for an Amgen Scholarship and attend Ignite Biotech Summer Program at no cost, please provide the contact information for your child’s school counselor or science teacher below:

Name:

telephone:

email:

You will be contacted the second week of May to inform you if your child has been accepted.