First Name
MIddle Name
Last Name
Suffix
Birthdate
Mobile Phone
Do you want to receive information by text message? Msg & Data rates may apply
Yes
No
Personal Email
In what county do you
live in?
Please select...
Cuyahoga
Ashland
Ashtabula
Columbiana
Erie
Geauga
Huron
Lake
Lorain
Mahoning
Medina
Portage
Richland
Stark
Summit
Trumbull
Tuscarawas
Wayne
If your high school isn't in Cuyahoga County, it may not appear in the list. Please select
"Other School"
if you can't find it.
School you are
currently attending?
Other School
What is your GPA?
Current Grade Level
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Graduate
List any careers that you are considering for your future. You may include one career or several. This can be a specific career (Ex. Pediatric Nurse) or a general career field (Ex. Medical Field). This information will be used to guide your internship placement if you are eligible and selected for the program so please include as much information as possible.
How did you hear about us?
Internet Search
JOG Teacher
PACE
Peer
Presentation
Sibling
Summer Jobs Case Manager
Teacher or School Personnel
Website
NASA Referral
Other
Parent/Guardian
Facebook
Instagram
Acknowledgement-
I understand that there are applications, interviews and additional screening steps and eligibility requirements for each internship and that completing this form does not guarantee I will be placed into an internship.
I understand
Hidden
School AccountId