BioBus Student Intake Form
Student Contact Information
Student First Name
Student Last Name
Student Email (if applicable)
Please ONLY put the student's email in this field. If the student does not have an email address, leave this blank.
Student Phone Number (if applicable)
Please ONLY put the student's phone number in this field. If the student does not have a phone number, leave this blank.
Student Background
Student's Date of Birth
T-Shirt Size
Please select...
Extra small
Small
Medium
Large
Extra Large
Student Gender
Please select...
Male
Female
Non-binary
Other
Student Ethnicity
Please select...
American Indian/Alaskan Native
Asian/Pacific Islander
Black
Hispanic/Latino
Mixed Race
Other
White
Other Gender Description
Other Ethnicity Description
What school do you currently attend?
School name will populate automatically as you type. If your school is not an option, please use the field below.
If your school does not appear in the above field automatically, please enter it here
Student History at BioBus
I have done a one-day session at a school with BioBus
I have done a multi-day program with BioBus (afterschool club, summer camp, etc.)
I have previously participated in a BioBus internship
I have applied for a BioBus internship before this year
No history at BioBus
Student's Household Address
Street Address
Include Apt Number on 2nd line, e.g.
1 Main Street
Apt 1A
City
State
Zip Code
Medical Information
Does this student have any allergies?
Please select...
Yes
No
Please list any allergens.
Does this student have any other condition that we should be aware of that may endanger, alter, or somehow limit his or her ability to participate in our program?
Please select...
Yes
No
Please describe the condition in detail:
Photo Release
Are you 18 or older?
Please select...
Yes
No
Does BioBus, Inc have permission to use this student's photograph(s), likeness and/or interview, in any form and in any media for advertising, publicity, trade or any other lawful purposes?
Please select...
Yes
No
Emergency Contact
Emergency Contact Info
First Name
Last Name
Phone number
Email
Relation to student
Please select...
Mother
Father
Grandfather
Grandmother
Uncle
Aunt
Sibling
Stepmother
Stepfather
Family Friend
Other relative
Financial Aid
Would you like to apply for financial aid for this class?
Please select...
Yes
No
Parents' combined income in 2019
Please select...
Under $20,000
$20,000-$35,000
$36,000-$50,000
$51,000-$74,000
$75,000-$100,000
Does your family income qualify you for Medicaid, SNAP, TANF, or other similar government aid? *
Please select...
Yes
No
Number of children in home
Any additional information that you would like for us to know?
Internship ID
Contact Information