Form

Full Name*
First Name Last Name

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone
- Area Code Phone Number
Cell Phone*
- Area Code Phone Number
E-mail Address*
Birth Date*
Month Day Year
Gender*
U.S. Citizen*
Current School*
Current Grade*
Need for Program Services*

Academic Tutoring College Visits Test Prep Study Skills Instruction Personal Counseling College Admissions Assistance Career Exploration Mentoring Educational Planning Financial Aid Assistance Cultural, Educational & Social Activities
With Whom Do You Live?*
Mother's Name*
Mother's Phone*
- Area Code Phone Number
Father's Name*
Father's Phone*
- Area Code Phone Number
Guardian's Name
Guardian's Phone
- Area Code Phone Number
Siblings*
Please list all siblings, their age and current grade level.
Academic Courses*
Please list all current classes and the grade received in each on the most recent report card.
Educational Plans*
Please select your educational intentions for after high school.
College Choices*
Please list two colleges that you are currently interested in.
Career Choices*
Please list two careers that you are currently interested in.
Ethnicity*

African American American Indian Hawaiian/Pacific Islander Hispanic White More Than One
Ethnicity Con't.
If chose "More Than One", please specify.
Mother's Education*
Please select the mother's highest level of education completed.
Father's Education*
Please select the father's highest level of education completed.
Guardian's Education
Please select the guardian's highest level of education completed.
How Many People Live in Your Household?*
Include any children away at school.
2012 Taxable Income*
Please select the range in which the family's 2012 taxable income falls in.
I hereby certify that the information provided, to the best of my knowledge, within this application is complete, current and accurate.
Student Initials*
Parent Initials*
Date*
Month Day Year
Please enter the text to the right in the box.*
Should be Empty:

I hereby certify that the information provided, to the best of my knowledge, within this application is complete, current and accurate.