Perry Virtual Experience Registration Form

Saturday, March 13th 9am- 11:30am CST

PLEASE NOTE: This session is exclusively for residents of LA, AR, MS, and AL. If this doesn't apply to you, please check (https://perryinitiative.org/calendar/) for another session that's open to all locations.

First Name *

Last Name *

Email *

Day Phone *

Address *

City *

State/Province *

Zip *

If you have previously participated in a Perry Outreach Program, please state the program location and year below.

Previous Perry Outreach Program

School Name *

Current Grade *

Anticipated Graduation Year *

College Major (if applicable)

I am interested in *

Race

American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

The above information is collected for reporting purposes only and will not be used in the student selection process.

Ethnicity

The above information is collected for reporting purposes only and will not be used in the student selection process.

Why are you interested in participating in the Perry Virtual Experience? *

Timeout Warning

Perry Virtual Experience Registration Form