Pi515 Registration Form

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Welcome to Pi515. We are excited for you to join our programs.

First name: *

Last Name:
*

Date of Birth:
*

YYYY

Which program are you registering for?
*

Tech Mentorship

SMART Money

SMART Cities

Girl's Entrepreneurship Incubator (GEI)

AI Challenge

Career Accelerator

Other:

What year (YYYY) are you currently registering for?
*

Have you participated in previous Pi515 programs?
*

Yes

Grade:
*

6th

7th

8th

9th

10th

11th

12th

Post High School

Phone number: *

Personal Email:
*

City: *

Altoona

Ankeny

Clive

Des Moines

Grimes

Johnston

Pleasant Hill

Urbandale

Waukee

West Des Moines

Windsor Heights

Other:

Street Address:
*

State: *

Iowa

Other:

Zip Code: *

School: *

Brody Middle School

Callahan Middle School

Cowles Montessori Middle School

Goodrell Middle School

Hiatt Middle School

Hoyt Middle School

McCombs Middle School

Meredith Middle School

Merrill Middle School

Middle School Alternative School

Dowling High School

East High School

Hoover High School

Johnston High School

Harding Middle School

Lincoln High School

North High School

Roosevelt High School

Ruby Van Meter High School

Valley High School

Waukee High School

Virtual Campus

Other:

Do you attend any classes at Central Campus or Central Academy:
*

Yes

Current Weighted GPA on 4.0 Scale:
*

3.70 - 4.00

2.70 - 3.69

1.70 - 2.69

1.69 and below

On a scale of 0 to 10, how interested are you in your current education?
*

No interest

Very high interest

On a scale of 0 to 10, how concerned are you about paying for college?
*

None

Very high

On a scale of 0 to 10, how dedicated are you to furthering your education and career?
*

None

Very high

Rank motivation for pursuing career goals:
*

Curiosity

Family

Financial Gain

Self-Validation

Required

After high school (select what best applies):
*

I plan to attend a four-year university

I plan to attend community college

I plan to attend a community college, then transfer to a four-year university

Vocational Trade School

Regular Employment after Highschool

Not sure yet

Allergies:
*

None

Other:

Illnesses:
*

None

Other:

Medication:
*

None

Other:

Disability:
*

None

Prefer not to answer

Other:

Do you have Internet access at home?
*

Yes

Do you have access to a personal computer at home?
*

Yes

Race:
*

White

Black

Hispanic / Latino

Asian

American Indian / Alaska Native

Native Hawaiian

Pacific Islander

Multi-Racial (More than 1 race)

Were you born in the United States:
*

Yes

If you were born outside of the United States, select which country you were born in:

Identified Gender:
*

Female

Male

Gender variant/non-conforming

Prefer not to say

Is English the primary language spoken in your household:
*

Yes

Please list all languages you speak or is spoken at your household:
*

Number of people in your household (not including yourself):
*

Do you currently receive public assistance benefits? Check all that apply. *

Free or reduced lunch

Household receives SNAP (food stamps)

Household receives Medicaid

Other

None of the Above

Other:

Required

Parent/Guardian First Name:
*

Parent/Guardian Last Name:
*

Relation:
*

Mother

Father

Parent/Guardian

Other:

Phone number for Parent/Guardian:
*

Email for Parent/Guardian:
*

Primary language of Parent/Guardian:
*

English

Other:

Emergency contact First Name:
*

Emergency contact Last Name:
*

Phone number for Emergency contact:
*

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