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By continuing to use this website, you consent to this usage in accordance with our Privacy Notice. https://www.fitchburgstate.edu/about/privacy-policy/AcceptCancelFuture Falcon Academy at Fitchburg State UniversityCoordinator: Lourdes Ramirez, School of Education at Fitchburg State University Email: lramire1@fitchburgstate.edu Phone: 978-665-3685 Loading...Student InformationFirst Name *Middle Name(leave blank if no middle name)Last Name *Student Email Address *Student Cell Phone Number (IF THE STUDENT HAS ONE)Birthdate *Birthdate *JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember123456789101112131415161718192021222324252627282930312026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900Gender *Gender *FemaleMaleAndrogyneDemigenderGenderqueer or Gender FluidNon-BinaryPrefer not to DiscloseQuestioning or UnsureTrans ManTrans WomanHome AddressHome Street Name and Number (include Apartment number, if applicable): *City: *State: *Zip Code: *Language spoken at homeLanguage spoken at homeAmerican Sign LanguageArabicEnglishFrenchGermanHaitian CreoleHindiItalianJapaneseLatinNepaliPortugueseSpanishEthnicityEthnicityAmerican Indian or Alaska NativeAsianBlack or African AmericanCape VerdeanNative Hawaiian or Other PacificWhiteLatino or HispanicSchool your child currently attends *School your child currently attends *Ayer Shirley Regional Middle SchoolGardner Middle SchoolLongsjo Middle School in FitchburgMemorial Middle School in FitchburgSamoset Middle School in LeominsterSky View Middle School in LeominsterHigh School Graduation Year *High School Graduation Year *JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember20002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040204120422043204420452046Has your child previously participated in Future Falcon Academy? *Has your child previously participated in Future Falcon Academy? *YesNoDates: Choose one date you prefer your child attends: *Dates: Choose one date you prefer your child attends: *Tuesday, February 17, 2026 - Friday, February 20, 2026Tuesday, April 21, 2026 - Friday, April 24, 2026Student Health InformationDoes the student have any food allergies? *Does the student have any food allergies? *YesNoList allergies here and describe the type of reaction the student experiences: *Does the student have any chronic medical issues?(Ex: Diabetes, allergies, asthma) *Does the student have any chronic medical issues?(Ex: Diabetes, allergies, asthma) *YesNoPlease list below: *Does the student carry an Epi-Pen or inhaler? *Yes - Epi-PenYes - InhalerDo not carry one, but need itDo not need oneIs there any other information Fitchburg State should be aware of?Primary Emergency Contact InformationPrimary Emergency Contact Relationship to student *Primary Emergency Contact Relationship to student *BrotherFatherGrandparentLegal GuardianMotherOtherParent/GuardianSisterStep-FatherStep-MotherPrimary Emergency Contact First Name *Primary Emergency Contact Last Name *Primary Emergency Contact Email Address *Primary Emergency Contact Cell Phone *Primary Emergency Contact Work Phone Number[HIDDEN]: Assign Emergency Contact[HIDDEN]: Assign Emergency ContactYesNoIf primary emergency contact cannot be reached, please provide information below of an alternative contact person belowAlternate Emergency Contact Relationship to student *Alternate Emergency Contact Relationship to student *BrotherFatherGrandparentLegal GuardianMotherOtherParent/GuardianSisterStep-FatherStep-MotherAlternate Emergency Contact First Name *Alternate Emergency Contact Last Name *Alternate Emergency Contact Phone Number *[HIDDEN]: Assign Emergency Contact2[HIDDEN]: Assign Emergency Contact2YesNoI grant my full permission to Fitchburg State University to secure emergency medical treatment if needed. I further agree not to hold Fitchburg State University and its personnel liable for any injuries sustained by the participant. I understand, in conditions of non-emergencies, that I will be called and requested to pick up the participant from the program for a time period determined by their health status. *I grant my full permission to Fitchburg State University to secure emergency medical treatment if needed. I further agree not to hold Fitchburg State University and its personnel liable for any injuries sustained by the participant. I understand, in conditions of non-emergencies, that I will be called and requested to pick up the participant from the program for a time period determined by their health status. *YesNoTransportationFitchburg Public Schools will be providing transportation to and from Fitchburg State University for the Future Falcon Academy. Parent/Guardian will receive the information in an email.My child will need transportation FROM this address in the morning. If yes, indicate the exact address.My child will need transportation TO this address in the afternoon. If yes, indicate the exact address.T-Shirts We will be providing free T-shirts for students to wear while participating in the Future Falcon Academy. What size t-shirt does your child prefer? *T-Shirts We will be providing free T-shirts for students to wear while participating in the Future Falcon Academy. What size t-shirt does your child prefer? *SmallMediumLargeExtra Large1XL Photo ReleaseI understand that Fitchburg State University is seeking photographs for publications, use on websites, and press, to assist in informing the general public about the Future Falcon Academy at Fitchburg State University. I authorize and consent to being photographed, and to the display, reproduction, alteration, and/or use of any photographs of me, or in which I may be included with others, in connection with Fitchburg State University publications, websites and press contacts. To the extent that I have any rights, title, and/or interests in the photographs, I assign such rights, title and/or interests to Fitchburg State University. In giving this permission, without fee and in consideration of the opportunity to participate in the publications, or and/or dissemination of press material, I agree to release, discharge, and hold harmless Fitchburg State University and its employees, from any and all claims, actions, and demands or whatsoever nature, including but not limited to any claims of libel, or invasion of privacy, arising out of or in connection with the use of my photograph. * I understand that Fitchburg State University is seeking photographs for publications, use on websites, and press, to assist in informing the general public about the Future Falcon Academy at Fitchburg State University. I authorize and consent to being photographed, and to the display, reproduction, alteration, and/or use of any photographs of me, or in which I may be included with others, in connection with Fitchburg State University publications, websites and press contacts. To the extent that I have any rights, title, and/or interests in the photographs, I assign such rights, title and/or interests to Fitchburg State University. In giving this permission, without fee and in consideration of the opportunity to participate in the publications, or and/or dissemination of press material, I agree to release, discharge, and hold harmless Fitchburg State University and its employees, from any and all claims, actions, and demands or whatsoever nature, including but not limited to any claims of libel, or invasion of privacy, arising out of or in connection with the use of my photograph. * YesNo My child and I discussed the Future Falcon Academy and my child wants to participate. * My child and I discussed the Future Falcon Academy and my child wants to participate. *YesNoFitchburg State University Permission to Participate I grant my full permission for my student to participate in the Future Falcon Academy at Fitchburg State University. Permission includes all activities and permission to be transported by the program for designated activities. *Fitchburg State University Permission to Participate I grant my full permission for my student to participate in the Future Falcon Academy at Fitchburg State University. Permission includes all activities and permission to be transported by the program for designated activities. *YesNo In place of your signature, please type your full name: *Click to Sign...[HIDDEN]:Tag Assign: Future Falcon AcademySetUnsetSubmit