Impact 2020

We look forward to your participation in Close Up's IMPACT series – a unique and engaging virtual program designed to help students develop the skills necessary to pursue a passion, tackle a community need, and form a network with other young leaders from across the country.

To register for your session, please complete the enrollment form below.

If you have any questions, please email programsupport@closeup.org.

Student Name*

Student Email School Name

Birth Date (MM/DD/YYYY)
Grade in 2021-2022:*
Home Address*
Street Address

City State ZIP / Postal Code Student Phone Number
Parent Name*

Parent Email Parent Phone

For educational and funding reporting purposes, Close Up requests that you provide the following demographic information. Such information will remain confidential and will not be used at any time for selection or placement criteria for the Close Up programs. Please complete all items below. Your cooperation is greatly appreciated.

1. Are you are a member of a farm/migrant community:

2. Which best describes your school district?

3. Check here if you are Hispanic or Latino:

4. Which best describes you? (please select one or more):

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

5. Check here if you are a citizen of the United States:

You are enrolling in the following program:

IMPACT MS Winter 2022: January 25 - February 10

I have read and agree to the Terms and Conditions: Parent Initials Student Initials