Generously supported by Motorola Foundation and Advanced Bionics
Registration deadline is May 31, 2013.
* 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
* 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 Phone
* Phone Type (Select One) Voice TTY Voice and TTY Videophone
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)