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Silicon Valley African Productions
P.O. Box 51616
San Jose,
CA
95151. Phone: 408-649-5872
REGISTRATION
FOR
SILICON
VALLEY FUTURE STARS PROGRAM
Silicon Valley Future Stars program is an integrated and innovative afterschool program that focuses on youth cultural awareness and educational enrichment programs that include career training in technology, broadcasting and performing arts. The program is operated by
Silicon Valley African Productions, a non-profit
San Jose based organization. It is a well known fact that teenagers do not like to be seen going into a homework centers for assistance, but, they love instant positive rewards, publicity, high paying jobs, and television/media spotlights. So we use this enrichment program as an academic/civic commitment incentive, and innovation outlet/spotlight for paving a brighter future for the participants. The Future Stars program is to open to all middle School and high school students in the Silicon Valley of California. Please register!
Student Last Name:_____________________ First Name: _____________________MI ______
Date of Birth: ___/___/____ Gender: _____ Ethnicity: _______________ Grade:____GPA:______
Address:________________________City:________________State:____Zip Code: ________
Phone: (___)___________ Cell: (___)___________ Email: ____________________________
School: _________________________________School District:________________________
In addition to Tutoring, ACT/SAT and AP Test Preparation, Mentoring, Conferences and Workshops, community service, Internship and Work Experience, I am interested in ___Math, Science and Engineering Empowerment*, ___Cultural and Performing arts,* ___Computer And Technology Access And Skill Development*,
___Media Production and Broadcasting Skill Development: Graphics, Video, Simulations & Game Production*
___Job Readiness Development*, ___Leadership And Entrepreneurial Skill Development* (Check ALL interest)
I certify that the information I have provided is true. I undertake to read and abide by the rules, regulations, policies and procedures of the Silicon Valley Future Stars program. I further commit to constant improvement of my academic performance to my maximum potential and sustaining excellence throughout my educational career.
Student Name: _____________________ Student Signature: _______________ Date: ___/___/____
How did you hear about the program? ____________________________________________
Please provide parent/guardian information
Guardian/Parent(s)____________________________________ Same Address as Student? YES/NO
Phone:(___)___________ Cell: (___)___________Email: ___________________________________ Number of persons in your household:_______ Annual Household Income: _____$0 - $ 15,000 ____$15,000 - $25,000 ____ $25,000 - $35,000 _____$35,000 - $50,000 _____Above $50,000
Highest Education:_________ Occupation: ______________________ Title:___________________
Company: ________________________________ Location: __________________________
I certify that I am 21 years of age or over, and the information I have provided is true. I undertake to read and abide by the rules, regulations, policies and procedures of the Silicon Valley Future Stars program. I further commit to sustaining active participation in activities/programs that positively support excellence in my student’s education.
_____ Yes. I am interested in being a parent volunteer.
______ I will donate $ __________ in cash, every year, towards the success of the program.
Parent Name: _____________________ Parent Signature: _________________ Date: ___/___/____
Thank you for your interest. You MUST read and sign the Program Policy and Procedure; complete and sign the Media Authorization/Release form and the Consent Letter to complete the registration. |
