Please note, completing this form does not guarantee you a spot on this trip.  It is merely an interest form to let us know which students are interested in attending.

Please complete all required sections below.

First Name *

Last Name *

Grade Level *
- Select Option 11th grade 12th grade

If you're in 12th grade, are you planning to apply for the MICAPP scholarship? *
- Select Option Yes No Maybe I'm not in 12th grade

Phone *

Email *

Address Line 1 *

Address Line 2

City *

State *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Zip Code *

Please write a paragraph telling us why you want to go to the Student Leadership Conference. *

Did you discuss this potential trip with a parent/guardian? *
- Select Option Yes No

Can you be excused from school March 7? *
- Select Option Yes No I'm not sure

What is your current GPA (grade point average)? Please enter a number between 0.00 and 4.00 *

Please note, if you are selected to participate in this opportunity, there will be additional forms to complete.