Ebersole Institute Interest Form

Directions: Thank you for your interest in the Ebersole Institute. By completing this form, you are one step closer to taking advantage of this exciting and dynamic learning opportunity. Please fully complete, and submit, the interest form below. Should you have any questions or concerns please do not hesitate to contact me at 517-755-5001.

With gratitude and appreciation, Ben Botwinski (Ebersole Director)

Ebersole Institute for Environmental Education - Interest Form

Student Information

Student's Legal First Name:

Student's Legal Last Name:

Student's ID #:

Student's School (2022-2023):

Student's Date of Birth (DOB): MM/DD/YYYY

Student's Phone Number:

Student's Email:

Parent/Guardian Information

Parent/Guardian's First Name:

Parent/Guardian's Last Name:

Parent/Guardian's Phone:

General Interests

Why are you interested in enrolling in the Ebersole Institute? Please select any of the topics or programs elements that interest you. Extra academic support Additional opportunities to earn credits Chance to help shape a brand new program 2nd semester residential experience Environmental education and stewardship Unique internship opportunities Hands on, minds on learning All of the above None of the above

In the space provided, please list any areas or topics that you would like additional information about moving forward.

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11,500 Enrollment by 2025

85% Graduation Rate by 2025

90% Attendance by 2025