| Springfield College

First Name

Last Name

What pronouns would you like for us to refer to you?

Some examples include: she/her/hers, they/them/theirs, and he/him/his

Street Address

City

State

Zip Code

Phone Number

What school do you currently attend?

Are you in the 9th, 10th, or 11th grade?

What is your preferred T-shirt size?

Are you seeking a scholarship? If yes, how much?

EMERGENCY CONTACT INFORMATION

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Home Phone Number

Emergency Contact Work Phone

Emergency Contact Email

Emergency Contact Relationship to Applicant

Please share, in approximately 250 words, why you are interested in participating in the Social Justice and Health Professions Academy and what you hope to gain from the experience.