Students to Launch: SpaceX Crew-5

Student Name*

First

Last

Date of Birth*

day

/

month

/

year

Email (of Parent or Guardian)*

Emergency Contact *

First

Last

Relationship to Student*

Emergency Contact Phone*

Address*

<input type="text" id="street1" class="street1" style="outline:none; border:none; background:none;" value="Street Address" disabled=""> Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Current School Attending*

Grade Level *

T-Shirt Size*

Gender

Female

Male

Non-Binary

Race and Ethnicity

Hispanic or Latino

African American

Asian / Pacific Islander

Native American

White

Other

Does your family quality for government assistance programs?

Yes

No

Please list any allergies, medical information, medications needed, or any other important information for travel purposes. *

In 150 words or less, tell us how will attending the Crew-5 launch make a positive impact for you and your community. *