Which school or organization recommended you for this experience? *

Student First Name *

Student Last Name *

Address 1 *

Address 2

City *

State/Province *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Zip/Postal *

Email Address *

Cell Phone Number *

Birth Date *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

High school attended this year (2021-2022): *

Grade level starting Fall 2022 *
- Select Option 11th grade 12th grade Not listed Please specify a value for Grade level starting Fall 2022

Did either of your parents graduate from a four-year college or university? *
- Select Option Neither One Both

Will you need to borrow technology equipment to participate in the program (free shipping)? *
- Select Option Digital Hotspot & Laptop No

GVSU will provide reasonable accommodations to individuals with disabilities upon request. For questions about accessibility please contact [email protected].

Do you need accommodations? *
- Select Option Yes No

Please share your requested accommodations. *

Option to upload requested accommodations.
Please upload a file with the extension .doc, .pdf, .rtf, .docx, .pub, or .txt with a maximum size of 1 MB (1024 KB)

Parent/Legal Guardian/Foster Parent First Name *

Parent/Legal Guardian/Foster Parent Last Name *

Parent/Legal Guardian/Foster Parent Email *

Parent/Legal Guardian/Foster Parent Cell Phone Number *

Parent/Legal Guardian/Foster Parent Alternative Phone Number *

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

Part 1

July 21, 2022, 9 a.m. to 6 p.m.
GVSU Allendale Campus

July 23, 2022, 9 a.m. to 6 p.m.
GVSU Detroit Center

Cohorts select one date/location above and attend together

Part 2

July 26-29, 2022, 10 a.m. to 4 p.m
Virtual

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