FIS Intake and Exit Form

Frontline Innovation Studios Genius Questionnaire

Fill out the form completely to be an eligible participant
Date

MonthDayYear
Date
Which is most interesting to you (Select one):

RoboticsCodingBroadcast (Digital)Broadcast (Communications)Financial AwarenessCareerFitness & HealthNone
Your Information
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
What school do you attend?
What grade are you in?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail
Phone Number

Area CodePhone Number
How do you see yourself in the future? What do you want to be or do? What are your passions?
What is the child's academic (in school) performance? What is the child's drive, motivation, punctuality, social behavior? What are the ways that the child learns? Other questions?
What are your interests? Your special gifts? What are you naturally good at , athletic, creative or academic?
Your Parent's Information
Parent Name

First NameMiddle NameLast Name
Parent E-mail
example@example.com
Parent Number

Area CodePhone Number
Alternate Number

Area CodePhone Number
ABOUT ME
What Are Your Favorite/Least Favorite Subjects?
Which Subjects Are You Struggling With?
Can your parents pick you up at 6 PM every day?
What are some achievements you’re proud of?
What motivates you to learn more?
STUDENT PROGRAM AGREEMENT
As a FIS Genius, I am required to maintain A's & B's in all of my academic classes. I must display integrity and character while in the program and when I am out and about. I will be open minded and have a positive attitude about learning a new task.
I have read and agree to all terms set forth in this document.
[TYPE FIRST AND LAST NAME TO SIGN AND SUBMIT]
Signature

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Exit Review

We would love your feedback on how you enjoyed the cohort!
Date

MonthDayYear
Date
What was your favorite program this cohort?

RoboticsCodingCareerBroadcast (Digital)Broadcast (Communications)Health & WellnessNone
What did you learn this cohort that you did not know?
What's something that the program does not currently offer that you would like to see us bring online?
How many stars would you give the Robotics program?

1 being the least and 5 being the most
How many stars would you give the Coding program?

1 being the least and 5 being the most
How many stars would you give the Financial Awareness program?

1 being the least and 5 being the most
How many stars would you give the Career program?

1 being the least and 5 being the most
How many stars would you give the Broadcast (Digital) program?

1 being the least and 5 being the most
How many stars would you give the Broadcast (Communications) program?

1 being the least and 5 being the most
How many stars would you give the Health & Wellness program?

1 being the least and 5 being the most
Signature

Clear
Have a question, Concern or comment?

Give us a call at 407.293.3000

or email info@frontlineoutreach.org
Should be Empty:

Frontline Innovation Studios Genius Questionnaire

ABOUT ME

Exit Review