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Student Enrichment Form

[vc_row content_type=”full_width_bg_content” pattern=””][vc_column][vc_fancyheading heading=”h2″ align=”center” textcolor=”#1d2f4e” text=”Student Enrichment Programs”]Student Program Application[/vc_fancyheading]

Step 1 of 2

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Today's Date
Date Format: MM slash DD slash YYYY
Program (Select one)*
- Cacho Academy
- Career Conversations
- Intership Sponsoring Program
- Raising the Bar
- Tutoring in Math and English
- Youth Council
Program Start Date
Date Format: MM slash DD slash YYYY
Program End Date
Date Format: MM slash DD slash YYYY
Student Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Gender
- Male
- Female
Date of Birth
Date Format: MM slash DD slash YYYY
Are you a United States Citizen?
- Yes
- No
Do you have a valid passport?
- Yes
- No
Ethnicity
- American Indian/Alaskan Native
- Asian or other Pacific Islander
- Black or African American (not Hispanic)
- Haitian
- Hispanic or Latino
- White (not Hispanic)
- Other

Student Academic Information
School Name:
Grade Level:
Estimated GPA (or LGA):
Actual GPA (or LGA):
Parent/Guardian Information
Parent/Guardian Name
First Last
Parent/Guardian Phone
Parent/Guardian Email

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Step 1 of 2

Student Information

Student Academic Information

Parent/Guardian Information