Student Interest Form

Please fill out this form if you are interested in learning more about applying to Breakthrough or if you plan to apply to Breakthrough. If you have questions, please write them in the final question and a Breakthrough staff member will contact you. Please note that this form IS NOT the actual application to Breakthrough. To be considered for admission, you must complete the full application that you can either receive through a school recruitment visit or by requesting one in the mail.

General Information

Grade - What is your current grade?: *

5th

6th

Site - Where will you be applying?: *

Germantown Friends School

Saint Joseph's University

Did you learn about Breakthrough because of a presentation at your school?: *

Yes

If you answered no, please describe how you learned about Breakthrough.:

Your Information

First Name: *

Last Name: *

Gender: *

Male

Female

Date of Birth: *

Current School: *

Home Address: *

Email Address (If you have one):

Home Phone Number: *

Cell Phone Number:

Race / Ethnicity (Optional):

Academic Information

Please provide your current grades in each of the following subjects. If you're unsure of your exact grade, you may estimate as closely as possible. You will be required to include a report card in your actual application.

Reading / English: *