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Select a Future Genius Summer Program
Choose State
*
(Choose One)
Vermont
Student Information
Student
*
Nickname (optional)
Gender
*
(Choose One)
Male
Female
Non-Binary
Prefer to self-describe
Date of Birth
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
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3
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30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
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1932
1931
1930
1929
1928
1927
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1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Age should be between 10 and 15 as of July 30th, 2022
Grade (Entering in Fall 2022)
*
(Choose One)
6th Grade
7th Grade
8th Grade
9th Grade
School
*
Medical Information
Does the student have any allergies or medical conditions we should know about (Ex: drugs, food, asthma)?
*
(Choose One)
No
Yes
Is the student taking any medications at this time?
*
(Choose One)
No
Yes
Does the student have any special learning, physical, behavioral, or emotional needs or limitations?
*
(Choose One)
No
Yes
Student's Physician
*
Physician's Phone Number
*
Insurance Provider
*
Name of Policy Holder
*
Policy Number
*
Continue to Parent/Guardian Info >
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