Online Registration
You must complete all the fields with asterik.

Basic Information

         
First name *   Last name *   Middle Initial  
     
Date of Birth *   Gender *
 

Current Address (please include apt number in street address)

Address: *
City: * State:* Zip: * -

Contact Information (A home phone number and an email address is required)

Home Phone: * ( ) -        
Cell Phone: ( ) -        
E-mail: *
Alternative E-mail:
Parent E-mail:

Underrepresented or First Generation College Bound? (You must check at least one.) *
I am a member of an historically underrepresented group (African American or Black, Native American or Alaskan Native, Mexican or Mexican American, Hispanic, Latino, or Puerto Rican).
I am a first generation college bound student whose parents/guardians have no education beyond high school. Race and ethnicity are not factors.

Ethnicity (You must check at least one) *












Religion: *



Career Major: *


High School Graduation Date: *


CEEB Code *  Click here to look up code in a new window


Current GPA:   Class Rank: I am out of a class of
        (number)   (number of students in graduating class)

Standardized Test Scores *
Please indicate the tests you have taken, and record the test date, and scores for each exam.

PSAT
Date Taken Math Evidence-Based Reading and Writing  
 
PLAN
Date Taken Composite Math English Reading Science
SAT
Date Taken Math Evidence-Based Reading and Writing
 
ACT
Date Taken Composite Math English Reading Science


Please indicate the highest level of your parents' or legal guardian's educational background:

Mother/Legal Guardian:







Father/Legal Guardian:








Please indicate, for the most recent year, the range of your family's gross income as reported on the Federal and/or State Tax Return.
Less than $10,000
$10,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 or more

Please select the math class you are currently taking. If you are not currently taking a math class, please select the highest level course you have completed. *









Please select the science class you are currently taking. If you are not currently taking a science class, please select the highest level course you have completed.





AP Courses






































Are you taking IB or have you completed (International Bacalaureate) courses? * Are you taking or have you completed any college level courses? *





What extra curricular activities have you participated in?













You must check the following in order to take advantage of the Ventures Scholars Program opportunities:
* I certify that this information is complete and correct to the best of my knowledge.
* I authorize the Ventures Scholars Program to provide my information to colleges, universities, and associations that will help me pursue my career goal.



 

 
© 2016 Ventures In Education, Inc.