Program Application
Downloadable Program Application
The Become program
tuition is based on a sliding scale, which includes
a $100 registration fee, all course materials,
and meals. If you require financial assistance,
please also complete a scholarship
application.
General Info
First Name
Last Name
Middle Initial
Address
City
State
Zip
Telephone
Email
Please check one:
Date of Birth (M/D/Y)
Age
Emergency Contact Name
Phone
Parent/Guardian/Sponsor
Info
If you are under the
age of 18, please provide the name(s) of your
parent, guardian, or program sponsor.
First Name
Last Name
Telephone
Email
First Name
Last Name
Telephone
Email
Education
Current Grade if still in school
or Graduation
Year
School attending (if
applicable)
GPA
Favorite Subject in School
Least Favorite
Subject
Hobbies, passions or
crafts
Extra-Curricular Activities
School Groups
Awards, Offices Held
Activities, Teams
Volunteer Work
Additional Information
How do you learn best?
Do you have any learning challenges? If so,
please share with us and tell us how we can
best accommodate your needs.
References
1. Please provide two
references.
Name
Phone
Relation to you
Name
Phone
Relation to you
2. Please mail one
letter of recommendation from a person other
than a family member (ie: teacher, coach, employer,
etc) to the Become office.
3. What are your future
educational and career goals?
4. Please write a brief
statement explaining why you would like to participate
in the Become program.
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