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LongfellowLEARNs 2021-2022 Program Application
$25 non-refundable registration fee* due prior to enrollment. (Check or money order made payable to PUSD. No cash accepted.)
*Registration fee waived for students who qualify for free/reduced lunch.
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* Indicates required question
Email
*
Your email
Student Information
Student Last Name
*
Your answer
Student First Name
*
Your answer
Gender
*
Male
Female
Non-binary
Prefer not to state
Date of Birth
*
MM
/
DD
/
YYYY
Race/Ethnicity
*
Decline to State
Asian
Hispanic or Latino
Black or African American
White
Middle Eastern
Multiracial
Native Hawaiian or Pacific
American Indian or Native American
Other:
Grade in Fall 2021
*
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K
1
2
3
4
5
6
7
8
Student ID#
Your answer
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