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 *
6th7th8th9th

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:

What subjects are you interested in? *

Do you have any programming or computer science experience? If so, please describe and include the name of the program, how long you participated and what you learned. *

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 program page.