Space Trek Application

Student Name:*
Current Age:*
Date of Birth:*
Student Phone:*	( ) - Second three digits Last four digits
Student Email:*
Mailing Address:*
Current School:*
Current Grade Level:*
Parent/Guardian Name (1):*
Parent/Guardian Phone (1):*	( ) - Second three digits Last four digits
Parent/Guardian Email (1):*
Parent/Guardian Name (2):
Parent/Guardian Phone (2):	( ) - Second three digits Last four digits
Parent/Guardian Email (2):
Are you a Youth Career Connect (YCC) student?:*	Yes No
If yes, please provide the name of your YCC career counselor:
If yes, please provide the email address of your YCC career counselor:
Why do you want to attend SpaceTrek? (Please upload 1000 words or less):*
Upload coupon:	Take a pic or scan your coupon and upload the file here.