Rawls Scholars Medicine Initiative*

Student E-Mail Address ■

Student's Last Name ■

Student's First Name ■

Gender ■

Female
Male

Birthday ■

01/01/1999

Parent/Guardian E-mail Address ■

Parent/Guardian First & Last Name ■

Sarah Hill

Address, Apt #, City, State, Zip Code ■

2011 Up Hill Rd. Apt. B Indianapolis, IN 46555

Home Phone ■

317-123-4567

Work Phone

317-123-4567

Cell Phone ■

317-123-4567

How did you hear about CLD? ■

TV/Radio Commercial

My School

A Parent

Indiana Black Expo

HBCU College Fair

IBJ

Indianapolis Recorder

Other

Current School: ■

Career Goal:

Grade in School (Fall 2011): ■

Are you a 21st Centuray Scholar? ■

Self-Discovery/Career Exploration Graduation Year ■

Have you completed other CLD programs? ■

Select all that apply or choose 'No'

Jr. Self-Discovery/Career Exploration Project

Precious Miss

Project MR

Imani Book Club

Success Prep

Self-Discovery/Career Exploration

SAT Prep

No

How would you like to pay the registration fee? ■

I understand that by participating in CLD programs I am giving permission to be photographed and recorded for the purposes of ongoing promotion of the CLD organization, programs and events. ■

I am 18 OR I am the parent/guardian and give this student permission to participate. ■

Medical Career of Interest

i.e. Pediatrician, Surgeon, etc.

Personal tools

Sections

A program for 10th-12th grade

GRADUATES of

Self-Discovery/Career Exploration Project

Find out more or register below

ATTENDANCE MANDATORY at orientation/1st session

Registration Fee: $20

CLD is located at 2425 Dr. Martin Luther King Jr. Street, Indianapolis, IN 46208

Office: 317.923.8111 Fax: 317-923-8112