First Name *

Last Name *

Email address *

Cell Phone Number *

Address 1 *

Address 2

City *

State/Province *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Zip/Postal *

School or Organization Name *

Your Position/Role *

City *

State/Province *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Zip/Postal *

Please select your plans for engaging your cohort in Summit Part 2 (in-person). We will do our best to accommodate your selected date. *
July 24, 2024, 9 a.m. to 6 p.m. - GVSU Grand Rapids & Allendale Campus
July 25, 2024, 9 a.m. to 6 p.m. - GVSU Grand Rapids & Allendale Campus

Emergency Contact First Name *

Emergency Contact Last Name *

Relation to Adult Lead *

Emergency Contact Cell Phone Number *

GVSU will provide reasonable accommodations to individuals with disabilities upon request. For questions about accessibility please contact [email protected].

Do you need accommodations? *
- Select Option Yes No

Please share your requested accommodations. *

Option to upload requested accommodations.
Please upload a file with the extension .doc, .pdf, .rtf, .docx, .pub, or .txt with a maximum size of 1 MB (1024 KB)

W9
Complete, save, and upload your W-9 to receive your stipend upon successful completion of the experience.

PHOTOGRAPHY & VIDEO
Photographs and/or video will be taken during rep4 experiences. Your registration gives consent for any such photographs/video to be used for advertising and publicity purposes by Grand Valley State University, its licensees, and/or member organizations, and you waive all claims for any compensation for such use or for damages. Please read complete the REP4/GVSU Release Form before submitting this registration form.

BACKGROUND CHECK & CONDUCT REQUIREMENTS
In alignment with the Minors on Campus policy, an overview of electronic authorization for release of information background check will be sent to your email following registration. Your link to "Authorized Adult" training will follow in your registration confirmation email.

Completed W-9 *
Please upload a file with the extension .doc, .pdf, .rtf, .docx, .pub, .bmp, .gif, .jpeg, .jpg, .png, .tiff, or .txt with a maximum size of 20 MB (20480 KB)

Which of the following best describes you? *
- Select Option Asian/ Pacific Islander/ Pacific Islander/South Asian Black /African American Hispanic/Latino(a)/Latinx Native American/Alaskan Native/American Indian Middle Eastern White/ Caucasian Multiracial or Biracial, please specify A race/ethnicity not listed here, please specify

Multiracial or Biracial, please specify *

Another identity, please specify

Gender Identity (Please select all that apply): *
Man
Woman
Cisgender (you identify as the gender you were assigned at birth)
Transgender (you identify as something other than the gender you were assigned at birth)
Agender
Genderqueer
Non-binary
Another identity (please specify)
Prefer not to respond

Please specify, Another identity *

Do you identify as LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex, and/or asexual)? *
- Select Option Yes No Prefer Not to Answer

Did either of your parents graduate from a four-year college or university? *
- Select Option Neither One Both

Did you graduate from a four-year college or university? *
- Select Option Yes No Another education journey, please specify

Please list your alma mater *

Another education journey, please specify *

I have read and understand the partner commitments assigned to adult leads. Associated benefits are provided upon successful completion of the experience *
- Select Option Yes No