King Science Program Enrollment Form

Participant Gender*

Male

Female

Non-binary

Other

Prefer not to say

Services Interested In*

College Selection/Tours

Financial Aid Assistance

Academic Support/College Prep

Tech Activities

Career Coaching/Workshops

Services Received:*

College Selection/Tours

Financial Aid Assistance

Academic Support/College Prep

Tech Activities

Career Coaching/Workshops

Ethnicity*

African American/Black

American Indian/Alaska Native

Asian

Caucasian/White

Hispanic/Latino

Native Hawaiian/Pacific Islander

Citizenship*

U.S. Citizen

Permanent Resident

If Permanent Resident, Resident ID Number:

Non-Citizen

Contacts

Emergency Contact

Parent/Guardian 1 Contact

Same as above: Copy the contact fields from above

Name*

Relationship to Participant*

Phone Number*

Email*

Address*

Parent/Guardian 2 Contact

Health and Safety

Medical Conditions the participant has, including any allergies*

Please enter "N/A" if there are none

How will the participant be getting home?*

Late Bus

Walking

Parent/Guardian Pick-up

Is the participant a proficient swimmer?*

Yes

List of medication taken by participant*

Please enter "N/A" if there are none

Is the participant eligible for Free/Reduced Lunch?*

Yes

Supplementary Income

Government benefits: Social Security benefits, disability payments, unemployment benefits, Supplemental Nutrition Assistance Program (SNAP) benefits, Temporary Assistance for Needy Families (TANF) benefits, etc.

Investment income: Dividends, interest, rental income.

Other sources: Child support, alimony, pensions, etc.

Family Educational History

What type of career or types of careers is the participant interested in?*

Is the participant a Ward of the State (foster child)?*

Yes

Has parent/guardian 1 completed a 4-year (Bachelor's) Degree from a college/university?*

Yes

Not Applicable

Has parent/guardian 2 completed a 4-year (Bachelor's) Degree from a college/university?*

Yes

Not Applicable

What is the highest level of education the participant plans to complete?*

High School

Vocational Degree

Two-year College

Four-year College or Beyond

Annual taxable Income Range*

$0 - $23,475

$23,476 - $31,725

$31,726 - $39,975

$39,976 - $48,225

$48,226 - $56,475

$56,476 - $64,725

$64,726 - $72,975

$72,976 - $81,225

More than $81,226

All information provided will be kept in strict confidence in accordance with the Family Educational Rights & Privacy Act (FERPA), following standards set by FERPA and the participating school. I certify all information provided to be accurate to the best of my knowledge. I give permission for the release of information for Federal Grant reporting such as grades, attendance, test scores, and Post-Secondary enrollment verification to the AIM Institute and AIM’s Educational Programs Staff.

*AIM provides support for families entering or continuing their postsecondary journey and is not responsible for any costs associated with failure to add/drop classes within timeframes as defined by the university or institution.

I also give my expressed written permission for any pictures/videos taken in connection with the activities of the corresponding AIM Educational Program, to be used in publications (newsletters, television, websites, presentations, magazines, articles, etc.)