Hometowns Western District of New York (Fall 2026) Accepted Students Form

1. Legal Name

First

Last

2. Preferred Name

3. Permanent Address

Address Line 1

Address Line 2

City

State

Zip Code

4. Personal Email Address (Not School)

computers release or

5. Parent / Guardian Email Address

6. Emergency Contact #1

First

Last

Phone

Relationship

7. Emergency Contact #2

First

Last

Phone

Relationship

9. Do you have any food allergies or restrictions? Please list below:

10. Do you have any medical concerns of which the program staff should be aware?

Please select your city/courthouse:

Rochester (Kenneth B. Keating Federal Building)
Buffalo (Robert H. Jackson U.S. Courthouse)

This is where you will attend the program sessions.

11. How will you commute to the program?

I will be driving and will need parking
I will be dropped off
I will be using public transportation

12. When you arrive at the Courthouse, you will need to provide photo ID. Which of the following do you have?

Drivers License
Photo ID
U.S. Passport or Passport Card
I do not have a government issued photo ID

13. I confirm that I am able to attend the program orientation for the program on August 13 (Rochester students) or August 14 (Buffalo Students) from 8:30 a.m. to 3:30 p.m.

Yes
No

14. I understand my attendance is expected at all after school sessions and that I may only miss time due to an emergency or unavoidable circumstances. I should do my best to let Ms. Juliet know in advance of my absence.

Yes
No

15. If I do miss a session, it is my responsibility to make up all work completed during the session.

Agree
Disagree

16. I will be working with people who bring diverse personal experiences to this program. I will be respectful to anyone with whom I interact.

Agree
Disagree

17. I will fully participate and be engaged in each session of the program.

Agree
Disagree

18. For part of the program, we will be working on computers in small groups. Each person does NOT need a laptop but each group will need access to 2-3 laptops. Do you have a laptop you would be willing to bring on those days? (YOU DO NOT HAVE TO HAVE A LAPTOP TO PARTICIPATE FULLY IN THE PROGRAM.)

Yes
No

19. A brief bio (100 words or less) that will help us get to know you better.

20. When working in groups, what role or roles do you typically take? (you can select more than 1 response).

Group leader – organizes group members, helps facilitate completing work, ensures all members have a task and remain on task
Creative/Graphic designer – organizes layout/structure of product, ensures all work is legible and presentable, has artistic eye
Tech guru – knows how to work online programs and may record information from other members
Researcher – digs in to find resources and information to use in product
Presenter – shares project with larger group, asks clarifying questions to overall project organizers
Other (please specify)

Other (Question 20)

21. Fun Fact: We will be playing a get to know you game, so please provide a fun fact that will help your peers get to know you.

22. What is your favorite snack?

23. Please upload a yearbook/headshot style photo of yourself. This picture may be shared in publications related to this program.

Drag & Drop Files, Choose Files to Upload

Please include your last name in the file name. Example: Morris Photo

24. Please upload a signed copy of your permission slip. The paperwork can be printed, signed by your parent or guardian, and then either scanned and uploaded or take a photo and upload.

Drag & Drop Files, Choose Files to Upload

Please include your last name in the file name. Example: Morris Permission Slip

25. Please upload a signed copy of your release form. The paperwork can be printed, signed by your parent or guardian, and then either scanned and uploaded or take a photo and upload.

Drag & Drop Files, Choose Files to Upload

Please include your last name in the file name. Example: Morris Letter of Rec