YWCA of Lincoln : Programs & Services : Eureka! Girls Inc. : Apply For Eureka! : Apply Online For Eureka! Now

Contact Information

First Name (Required)

Last Name (Required)

Name of School (Required)

Current Grade (Required)

Home Address (Required)

City, State, Zip Code (Required)

Telephone Number (Required)

Participant's Cell

Participant's Email

Date of Birth (Required)

Parent/Guardian's Name(s) (Required)

Relationship to Applicant (Required)

Parent/Guardian Phone (Required)

Parent/Guardian Email (Required)

Emergency Contact Name and Number (Required)

To Be Filled Out By Participant

1. How do you think OTHERS would describe you? (Required)

2. How would YOU describe yourself? (Required)

3. What other school year or summer activities are you committed to and when/for how long do they meet? (Required)

4. What do you hope to gain from the Eureka!® Program? (Required)

5. What do you believe you have to offer the Eureka!® Program? (Required)

6. Why do you want to learn more about science, technology, engineering, and/or math? How do you think this program might help? (Required)

7. Is there a career (or job) you are really excited about having when you are an adult? (Required)

9. Do you know how to swim? Do you enjoy swimming? (Required)

10. Do you play any sports? Do you enjoy playing sports? What are your favorites and why? (Required)

12. Is there anything that would prevent you from attending Eureka!® this July 9th–August 3rd from 9:00 a.m. to 4:00 p.m. Monday to Friday? (Required)

To Be Filled Out By Parent/Guardian(s)

1. What are your personal hopes and goals for your child’s education? (Required)

2. Why do you want your child to attend this program? (Required)

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3. Can you commit your child to attending a full day, four week, intensive STEM and Leadership summer camp for the first two years of this program? Explain. (Required)

4. Is your daughter receiving any additional services at school or is she currently in special education services? If so, please explain so we can make sure to provide activities that will work for her if she is selected to participate. (Required)

5. Is there anything else you would like to share about your daughter? (Required)

6.. Are you and your child committed to actively participate in this program until your child graduates high school? Please explain “Yes” and “No” answers: (Required)

Recommendation

Please provide the name and telephone number of an adult (other than a family member) YWCA can call for a recommendation. This could be a teacher, a counselor, a coach, or a mentor. --OR--Attach and email leah@ywcalincoln.org a letter(s) of recommendation from the individual(s). Please be sure their contact information is included below. (Required)

Contact Information

To Be Filled Out By Participant

To Be Filled Out By Parent/Guardian(s)

Recommendation

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