Rochester Institute of Technology

* Student's First Name

* Student's Last Name

Date of Birth

* Home Address

* City

* State

* Zip

* Phone Number

Cell/Pager

* E-mail Address

* Size for your lab coat (Select One) Small Medium Large Extra-Large

* School Name

* Address

* City

* State

* Zip

* Student's Current Grade (Select One) 6 7 8

* Teacher's First Name

* Teacher's Last Name

* Teacher's Subject Area

* Teacher's Phone

Fax

* Teacher's E-mail

* Parent/Guardian's First Name

* Parent/Guardian's Last Name

* Home Address

* City

* State

* Zip

* Home Phone

* Phone Type (Select One) Voice TTY Voice and TTY Videophone

Fax

Cell/Pager

* E-mail Address

Do you have a hearing loss? Yes
No

* If yes, how do you prefer to communicate? (Select One) Speech and lipreading. I do not use sign language. Speech and sign language. American Sign Language only.

Your ethnicity: (If you wish to be identified with a particular ethnic group, please check the appropriate one.)

Select One African American,Black
Asian-American
Native American,Alaskan Native
Hispanic,Latino
Native Hawaiian,Pacific Islander
White,Caucasian

Other

How did you first find out about the TechGirlz program?

(Select One) Received information from NTID Found out about it from my school counselor or teacher Found out about it from a friend or family member Read about it online Saw the advertisement or article in (fill in below) Other

Name of publication or other (if selected)