To be completed by a parent/guardian of the student

Thank you for your interest in The Summit. To apply for the program, please complete the registration form for each participant.

Student Information

Student First name

Student Last name

Student Date of Birth

Month

Day

Year

School

Student Email

Student Address

Mentor Pairing

How did you hear about The Summit?

What are some of the student's hobbies and interests?

Parent Information

Father First Name

Father Last Name

Father Email

Father Cell Phone

Mother First Name

Mother Last Name

Mother Email

Mother Cell Phone

Medical Release

By signing below, I understand that I am signing as a parent or legal guardian of the applicant. In signing, I authorize The Summit staff to seek medical assistance for my son, should the need arise.

Medical Release

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Photo Release

By signing below, I understand that I am signing as a parent or legal guardian of the applicant. In signing, I authorize any photography that includes my son to be used for the purpose of promoting The Summit. I understand that such photography remains the property of The Summit.

Photo Release

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Additional Feedback

Long answer