| STUDENT INFORMATION: |
| Current Grade (2010-11 school year): 1 2 |
Date of Birth |
| Male Female |
Last Name |
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First Name |
Middle Initial |
Street Address |
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City/State/Zip |
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Name of Parents or Guardian |
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Home Phone |
Work Phone |
Parent Email |
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| All acceptance letters will be sent by mail. |
Name of School |
City |
| SELECT CLASS CHOICE IN ORDER OF PREFERENCE: |
| Period I Choices: |
Period II Choices: |
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| CHECKLIST FOR ALL APPLICATIONS: |
| completed application form $170 tuition Copy of Spring 2010 report card with comments |
| MAIL TO: |
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Minnesota Institute for Talented Youth
1600 Grand Ave. St. Paul, MN 55105
651-696-6590
www.mity.org |
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