BRYC
Prospective Fellow Form
Request Information
Student First and Last Name
*
Student Phone Number
*
Student Email
*
Student's school in 2019-2020 school year
*
Student grade in 2019-2020 school year
*
Select
8th Grade
9th Grade
10th Grade
11th Grade
How are your grades?
*
Select
All As
All As and Bs
As & Bs; 1-2 Cs
2+ Cs or lower
Mailing Street Address
*
Ex. 123 Alphabet Lane APT 10B
Mailing City
*
ex. Baton Rouge
Mailing Zip Code
*
ex. 70100
Parent/Guardian First and Last Name
*
Parent/Guardian Phone Number
*
###-###-####
Parent/Guardian Email
*
Parent/Guardian's relationship to student
*
Select
Mother
Father
Grandmother
Grandfather
Aunt
Uncle
Sibling
Other
Submit
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