Nomination Form Any educator or parent familiar with the student may complete the form below to nominate a student for our program. There is no cost to nominate a student. No information obtained here is used for any purpose other than relaying information to the nominated student's family. Please complete as much information as possible. Although not required, in order for us to process this nomination, we need an e-mail, phone number or address. Student Information First Name (Student) * Last Name (Student) * Nickname Gender * - Select -FemaleMaleTransgender Grade in School * - Select -45678 Birth Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Race (Optional) African-American or Black Asian Biracial or Multiracial Caucasian or White Eastern European Hawaiian or Pacific Islander Hispanic or Latino Middle Eastern Native American or Alaskan Native A Race/Ethnicity Not Mentioned Here/Other Prefer Not To Answer Parent/Guardian Name Prefix - None -Mrs.Ms.Mr.Dr.Sr.Fr.Msgr.DeaconBro.Deacon Bro.MissRabbiRev.Mr. & Mrs.Dr. & Mrs. First Name (Parent) * Please enter the first name of the student's parent(s). If you don't know it, please enter "Parent of (first name of student)" here. Last Name (Parent) Please enter the last name of the student's parent(s). If you don't know it, please enter the student's last name here. Street Address * Street Address Line 2 City * State/Province Postal Code * Phone Number (Parent) xxx-xxx-xxxx Email (Parent) How did you hear about Project MEGSSS? (For Parents) School-wide communicationChild's teacher in schoolFriendSummer fairPeachjar communication from schoolOther (please enter below) Other comments parent For other, please enter here. School School Name * Please enter the school the student currently attends, here. District Name Please enter the school district, if applicable. Additional Comments Free or Reduced Lunch Does the student qualify for free or reduced lunch (optional, if known)? Yes No Does the student live in the Rolla area? If the student lives in the Rolla area, click "Yes" below to provide information on Project MEGSSS' after-school program in Rolla. Yes please provide information on Rolla classes No, I am not interested in Rolla information Is there any other information that you would like to share about your student? Perhaps your child doesn't quite fit within our guidelines? We leave it to the parents and educators who know them best to make recommendations to MEGSSS. Please comment here if you want us to have any more information about your child. Teacher NominationsThis information is helpful in the event that there are questions about student qualifications for the program. If a teacher is not involved in the nomination, you may skip this section, fill in the CAPTCHA, and press the "Submit" button below to submit this form. Name Prefix - None -Mrs.Ms.Mr.Dr.Sr.Fr.Msgr.DeaconBro.Deacon Bro.MissRabbiRev.Mr. & Mrs.Dr. & Mrs. First Name (Teacher) Last Name (Teacher) Email (Teacher) How did you hear about Project MEGSSS? (For Teachers) Contacted by MEGSSS PersonnelStudent/parent/school administratorCollegue or friendSummer/curriculum fairOther (please enter below) Other comments teacher For other, please enter here. Thanks for nominating your student for Project MEGSSS! Once you fill in the CAPTCHA and press the submit button below, a confirmation e-mail will be sent to both parent and teacher e-mail addresses (if provided). If you experience problems with a nomination, please contact our office at 314.842.5968. Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * More information? Submit Nomination
