apply

The following form is a preliminary application form for The NET STEM and Mentoring programs. Once this is completed, a member of our team will contact you with the full application.

Please complete the preliminary application form below

Student Name

First Name

Last Name

Student Email Address

Student Home Phone

(###)

###

####

Student Cell Phone

(###)

###

####

Which program are you applying for?

School

Date of Birth

*Format: mmddyyy

Age

Student Grade level

Student GPA (or average grade if GPA unavailable)

Note: Student grades will not be used as a metric to determine acceptance into program

Does student have any disabilities that may require special care?

Does student have any learning disabilities? If so, please list disability and whether or not additional services or care is necessary.

Parent Full Name

Parent Email

Parent Phone

(###)

###

####

Apply

apply

Please complete the preliminary application form below

LOCATION

CONTACT