Information

First Name

Last Name

Phone Number

Email

Preferred Contact Method

Birthday

(MM/DD/YYYY - You must be between 16-24 to participate)

Home Address

City

State

Zip Code (5-Digit)

Last 4 Digits of your Social Security Number

Gender

Gender Pronoun

Race/Ethnicity (Select All that Apply)

American Indian or Alaskan Native	Asian
Black or African American	Native Hawaiian or Other Pacific Islander
White	Hispanic or Latino
Middle Eastern or North African	Other
Prefer Not to Say

Language(s) (Do you speak English and/or Spanish fluently, and/or do you speak any other languages Fluently? Mark All that Apply)

EnglishSpanishKinyarwandaOther

School Information

Which School do you Attend?

After the Tassel currently provides services to these schools.

What Grade are you in?

9th Grade	10th Grade
11th Grade	12th Grade

Professional Fields of Interest (Select all that apply)

HeathcareManufacturingLogisticsConstruction & TradesBusiness & Professional Services

Emergency Contact Information

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Emergency Contact Email

Emergency Contact Relationship

Legal Guardian

Parent

Friend

Other

SummerWorks is a collaboration between KentuckianaWorks, Blueprint502, and Louisville Metro Government.

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