Student Name *

First Name

Last Name

Are any of the following statements true? *

Please select all that apply.

I attend school in the U.S.

I’m studying 6th-12th grade course material.

I receive free or reduced price lunch at school.

I will be the first in my family to go to college.

I live in a single-parent home.

I am on or qualify for food stamps.

My parent(s) / guardian(s) do not speak English.

I am a first or second generation immigrant.

None of the above.

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone Number *

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