Name: First
Last
Company or University:
Job Title:
Job Description:
Department:
Level of Education : High School Some College Associate's Degree Bachelor's Degree Master's Degree Doctorate
Street Address:
City:
State: NC
Zip Code:
Phone: work ( ) home ( ) cell()
Email:
T-shirt size (unisex) : Small Medium Large XL XXL
School Preference (First Choice):
Brogden Carrington Durham School of the Arts Githens Lakewood Little River Lowes Grove Lucas Neal Rogers-Herr The School for Creative Studies Shepard
School Preference (Second Choice):
School Preference (Third Choice):
What languages other than English do you speak:
How did you learn about the program:
Do you have transportation to take two or three girls from school to a field trip?
Yes! No
Pre-arranged field trips are usually scheduled weekdays late afternoon, requiring absence from school/work. From January through May, do you have time to take at least 1 day off (8am until 3pm) AND at least an afternoon/evening once a month?
