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First name *

Last name *

Email *

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

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Home Phone *

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Parent/Guardian Email *

Language(s) Spoken at Home *

High school currently attending? *

Grade *

Current GPA *

Counselor *

Please place a check by the categories that most accurately describes your ethnic background *

African American

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If you stated "Other" above, please describe your ethnic background

Are you a U.S. Citizen? *

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If no, what is your country of permanent residency?

Check all that apply. I live with *

Mother

Father

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Legal Guardian

Have either of your parents completed a college degree? *

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Do you have free or reduced lunch? *

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Do you receive ESL services? *

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Do you have a documented disability (learning, physical, emotional, cognitive)? *

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If you answered yes, please describe:

Are you currently on an Individual Education Plan (IEP) at your school? *

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