Project SUCCEED: Information Request

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Directions: Use this form to be added to our mailing list or to request information. This is not an application form for our programs. If you would like to register for a program, please visit the SUCCEED Calendar of Events.

You can submit this form online by filling in the appropriate information and clicking on the "Submit" button at the bottom of the page, or you can print this form, fill in the information, and fax to (919) 530-1944.

Our mailing lists will not be distributed to any external organization.

Student's Name:

Name of Parent or Legal Guardian:

Address:

City:

State

Zip Code

Daytime Telephone Number

Evening Telephone Number

E-mail (if any)

Would you like to be added to our mailing list?

Grade of student (if you are a home school student, estimate an approximate grade level):

Age of student:

Check all of the subject areas that might be of interest to you:

Biology	Humanities	Geometry
Chemistry	Engineering	Algebra II/ Trig
Physics	Computer Science	Pre-Calculus
Meteorology	Marine Biology	Calculus
Cosmology	Discrete Math	Statistics
Environmental Science	Pre-Algebra	Medicine/Biomedical Sciences
Earth Science/Geology	Algebra	Other (describe below)

I'm interested in learning more about:

How did you hear about the program?

Additional comments or questions: