OUT Maine · 2022 - Haystack Nomination Form

Teacher / Advisor

I am a

*

Check all that apply

Art Teacher

GSTA Advisor

Teacher/Advisor Name

*

First Name

Last Name

Teacher/Advisor Email

Verify Email

Teacher/Advisor Cell Phone

*

Teacher/Advisor Work Phone

*

School

*

County

*

Student Participant

Graduation year

*

Must be a rising junior or senior.

Student's name (preferred name)

*

First Name

Last Name

Student's home address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Student's cell phone

*

Student's email

*

Verify Email

*

Parent/guardian

*

First Name

Last Name

Parent/guardian cell phone

*

Parent/guardian email

*

Verify Email

*

Workshops

Please indicate the student's order of preference. The student will be placed in one of these classes.

First Choice

*

Second Choice

*

Third Choice

*

Fourth Choice

*

Fifth Choice

*

Last Choice

*

Alternate Student Participant

In the event your first choice cancels, or if there is a cancelation from other schools.

Alternate's graduation year

*

Must be a rising junior or senior.

Alternate's name (preferred name)

*

First Name

Last Name

Alternate's home address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Alternate's cell phone

*

Alternate's email

*

Verify Email

*

Alternate's parent/guardian

*

First Name

Last Name

Alternate's parent/guardian cell phone

*

Alternate's parent/guardian email

*

Verify Email

*

Workshops (alternate)

Please indicate the student's order of preference. The student will be placed in one of these classes.

First Choice (alternate)

*

Second Choice (alternate)

*

Third Choice (alternate)

*

Fourth Choice (alternate)

*

Fifth Choice (alternate)

*

Last Choice (alternate)

*