What school/organization recommended you for this experience? *
- Select Option BCPS Berrien RESA Burma Center Canton Prep CapCAN Covert East Kentwood High School Grand Rapids University Prep Academy Lincoln King Academy Muskegon Public Schools Southwest Michigan Urban League TRIO Talent Search TRIO UB Grand Rapids TRIO UB Wyoming TRIO UB Detroit The Community Builders-Detroit Not listed Please specify a value for What school/organization recommended you for this experience?

Student First Name *

Student Last Name *

Email Address *

Phone *

T Shirt Size *

Which of the following best describes you? *
Asian/Pacific Islander/ Pacific Islander/South Asian
Black/African American
Hispanic/Latino(a)/Latinx
Native American/Alaskan Native/American Indian
Middle Eastern
White/Caucasian
Multiracial or Biracial, please specify
A race/ethnicity not listed here, please specify

Multiracial or Biracial, please specify *

A race/ethnicity not listed here, please specify *

Gender Identity (Please select all that apply): *
Man
Woman
Cisgender (you identify as the gender you were assigned at birth)
Transgender (you identify as something other than the gender you were assigned at birth)
Agender
Genderqueer
Non-binary
Another identity (please specify)
Prefer not to respond

Another identity, please specify

Do you identify as LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex, and/or asexual)? *
- Select Option Yes No Prefer not to answer

Midwest Learner Design Summit Overnight 1

July 15th- 16th 

Arrive July 15th 8:30 am, Depart July 16th 5:00pm 
 

Midwest Learner Design Summit Overnight  2
 

July 22nd-23rd  

Arrive July 22nd 8:30 am, Depart July 23rd 5:00pm 

Cohorts select one date from above and attend together

Overnight 1 or Overnight 2 *

I have read and understand the time commitment to participate in the Summit (Parts 1-2). Associated benefits are provided upon successful completion of the experience. *
- Select Option Yes No

♦Once you click the blue submit button below, you will see a submission page directing you to finalize your♦

2025 REP4 Midwest Learner Design Summit Part 1 Registration

Your registration is not complete until you finalize your Part 1 Registration