Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Home address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Gender
Male
Female
Prefer not to specify
Race
Black or African American
Hispanic or Latino
Native American or Alaska Native
Asian
Native Hawaiian or Pacific Islander
White
Prefer not to specify
DOB
*
If you're a minor, please ask a parent/guardian to fill out the following section.
MM
DD
YYYY
Name
First Name
Last Name
Email
Phone
(###)
###
####
Home address
(if different than above)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
I give permission for my student's participation in Rise Labs.
Media release
I give permission for my student's image/likeness to appear in photos and/or videos while participating in Rise Labs activities.
Enter name to indicate electronic signature.
Today's date
MM
DD
YYYY
Select the income range that best describes what your household earned last year.
*
Less than $10,000
$10,000–$15,000
$15,000–$20,000
$20,000–$25,000
$25,000–$30,000
$30,000–$35,000
$35,000–$40,000
$40,000–$45,000
$45,000–$50,000
$50,000–$75,000
$75,000+
I'm interested in
Employment: paid work experience so I can earn money
Internship: unpaid work experience to help me apply to college or a job
Workshop: free training to equip me for a future job opportunity
Personal enrichment: I want to learn something new
Job training options
Culinary Arts
Hydroponic Farming
Barista
Screen Printing
