Applicant Information:

First Name
Last Name
Gender M F
Birth Date
Address
City
State
Zip
Home Phone
Student Cell
Student E-mail


Present School
Student Grade
School Address
City
State
Zip
Guidance Counselor
Counselor E-mail
Counselor Phone
Counselor Fax
Phone


Parent Information:
Father First Name
Father Last Name
Address
City
State
Zip
Home Phone
Father Work Phone
Father Cell Phone
Father E-mail

Mother First Name
Mother Last Name
Address
City
State
Zip
Home Phone
Mother Work Phone
Mother Cell Phone
Mother E-mail


Parent Information:
Please submit a short-essay (no more than 500 words) on why you are interested in participating in the Kinetic Potential Scholars Program. In particular, you should talk about:
  • Your long term career ambitions (what would you like to be when you grow up)?
  • How you feel the Kinetic Potential Scholars Program will help you achieve this goal?
  • Also, tell us about yourself, where you live, and what your life is like.



 Code:

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The Kinetic Potential Speakers Bureau is committed to bringing
our clients the best speakers who reflect our Kinetic Potential Methodology and are passionate about serving as a role model and encouraging today’s youth to put their vision into motion.