SALSAForm

SALSAForm

Student First Name*

Student Last Name*

Home Address

Address Line 1*

Address Line 2

City*

State*

Zip Code*

State Representative*

Find My Elected Officials Map

State Senator*

Student Gender*

Select

Age at attendance*

Select

Student Ethnicity*

Select

Preferred date of attendance*

Week 39: June 22nd-June 27th

Week 42: July 13th-July 18th

Week 43: July 20th-July 25th

Second preference*

Week 39: June 22nd-June 27th

Week 42: July 13th-July 18th

Week 43: July 20th-July 25th

Third Preference*

Week 39: June 22nd-June 27th

Week 42: July 13th-July 18th

Week 43: July 20th-July 25th

Have you been awarded a SALSA Scholarship?*

Yes

No

Parent/ Legal Guardian first name*

Parent/ Legal Guardian last name*

Parent email*

Parent Phone #*

Phone

Student’s School Name*

School Address*

School zip code*

School Phone Number*

Phone

Student Essay Response: Please tell us what you hope to learn from attending Space Academy*

Please limit your essay to 300 words.

School Verification Form

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