Student Interest Form




Student Details






If you are on summer break, please indicate your upcoming grade level in the fall.


High School Name and City

##.# or #.## (ex. 95.5 or 3.95)

Our communications tools allow us to send messages through SMS with program updates and invitations.  If the student does not have a mobile phone, please enter the primary caregiver's mobile number.

If you do not have a home phone number you may leave this space blank

Our communications tools allow us to send messages through email with program updates and invitations.  If the student does not have an email address, please enter the primary caregiver's email address.




Additional Information

Additional State grants may be able to be coordinated for children who have been in a state foster care program.









Student mailing address



Primary Caregiver Contact Details





Third Party Contact Details







Need Assistance?

Give Back wants to support you as you get to know us!  Our Scholar Support Center is available many nights and weekends to assist you!  Click the button below if you would like to book an appointment to work through this step or to ask questions about our program.
You can also call our Scholar Support Center at 888.383.9877 (press 1 at the prompt).