Parent Questionnaire

Name of Parent: _____________________ Name of Student: ___________________
Address: ___________________________ School of Attendance: ________________
City: ________________ ZIP: ________ Career Interest: _____________________ Home Phone: ______________________
Work Phone: ______________________

Would you support your son’s/daughter’s involvement in the Academy?
Yes _____ No _____

Do you think your son/daughter would do well in this program?
Yes _____ No _____

How do you think your son/daughter would benefit from this program?

Additional information you feel would be helpful in the selection process:

Will you be willing to assist the Academy staff in the following? (Circle all that apply)

Tutoring Transportation Fund-Raising
Mentorship Material Donation On-the-Job Training
Parent Support Group Provide Field Trip Sites Guest Speaker
Financial Sponsor Chaperone Equipment Donation

Printed Parent/Guardian Name: ______________________________________________

Parent/Guardian Signature: ________________________________
Date: ___________