Student Information

First Name*

Last Name*

Email*

Project Information

Project Description (one sentence)*

Faculty Mentor*

Organization Information

Organization Name*

Organization Address*

City*

State*

Zip*

Supervisor Name*

Supervisor Email*

Supervisor Phone*

Approval

After you submit this form you will receive a confirmation email. Please print out the confirmation, have it signed as indicated, and return it to Ms. Hass.

Parent/Guardian Signature

Date

Faculty Mentor Signature

Date

On-Site Supervisor Signature

Date

Please send a confirmation email to the address below*: