Technology Leadership Initiative

Student Information

First Name *

Last Name *

Suffix

Address 1 *

Address 2

City *

State *
ALABAMAALASKAAMERICAN SAMOAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFEDERATED STATES OF MICRONESIAFLORIDAGEORGIAGUAM GUHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARSHALL ISLANDSMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTANORTHERN MARIANA ISLANDSOHIOOKLAHOMAOREGONPALAUPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGIN ISLANDSVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMINGARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFIC

Zip *

Email *

Home Phone *

Mobile Phone

Sex
MaleFemale

Ethnicity
African American, Black
Hispanic, Latino
Native Hawaiian
Asian
Caucasian, White
Native American, Alaska Native
Mexican American, Chicano
Pacific Islander
Puerto Rican
Other

Which (if any) TLI programs have you attended in the past?

Academic Information

School District *

School *

Grade you will be going into *
8th9th10th11th12th

Last Cumulative GPA (e.g., 3.14) *

Max possible GPA (e.g., 4.0) *

What statement below best describes how you first learned about TLI? *
Religious organization
School
Brochure
Email announcement
Community organization
Current or former TLI student
Poster
Word of mouth
Other:

When you graduate high school do you plan to go to a 4-year college/university? technical school? community college? What area(s) are you interested in studying? What are your career plans and interests? *

Do you currently have or plan to have summer employment? If so, does expected work schedule conflict with any program dates or times? Do you have any vacations or planned trips that conflict with your participation?

List any other information you may think relevant

Family Information

Applicant lives with (check all that apply)

Mother
Father
Relative
Step-Parent
Grandparent
Other:

Number of brothers

Number of sisters

Primary Parent/Guardian

First Name *

Last Name *

Suffix

Address 1 *

Address 2

City *

State *
ALABAMAALASKAAMERICAN SAMOAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFEDERATED STATES OF MICRONESIAFLORIDAGEORGIAGUAM GUHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARSHALL ISLANDSMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTANORTHERN MARIANA ISLANDSOHIOOKLAHOMAOREGONPALAUPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGIN ISLANDSVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMINGARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFIC

Zip *

Email *

Home Phone *

Alternate Phone

Sex
MaleFemale

Relationship *
ParentGuardianOther

Secondary Parent/Guardian

First Name

Last Name

Suffix

Address 1

Address 2

City

State
ALABAMAALASKAAMERICAN SAMOAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFEDERATED STATES OF MICRONESIAFLORIDAGEORGIAGUAM GUHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARSHALL ISLANDSMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTANORTHERN MARIANA ISLANDSOHIOOKLAHOMAOREGONPALAUPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGIN ISLANDSVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMINGARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EASTARMED FORCES AMERICA (EXCEPT CANADA)ARMED FORCES PACIFIC

Zip

Email

Home Phone

Alternate Phone

Sex
MaleFemale

Relationship
ParentGuardianOther

Emergency Contact

Other than parent/guardian

First Name *

Last Name *

Relationship *
Friend of the familyFamily memberCo-workerNeighborOther

Home Phone *

Alternate Phone

Personal Statement

Copy and paste your 100-300 word personal statement into the space provided below. *
See description of what should be addressed at the bottom of the progam page.