Data Entry 2

1. Contact Information

Tell us a bit about yourself. Enter as much information as you know. This information will be used by the Pierce College Bridge to Success program only.

Please complete the following information

Please complete the following information Last Name:
First Name:
Address:
City:
State:
ZIP Code:
Email Address:
Phone Number:

Please specify the following information

	MM		DD		YYYY
Date of Birth	Please specify the following information Date of Birth Month	/	Day	/	Year

Gender:

Gender: Male

Female

Last High School:

Last High School: Birmingham High School Canoga Park High School Chatsworth High School Cleveland High School	El Camino Real High School Granada Hills High School Grant High School John F. Kennedy High School	Monroe High School Panorama High School Taft High School Van Nuys High School
Other (please specify)

Last Year Enrolled (Class of):

Last Year Enrolled (Class of): 2004 2005	2006 2007	2008 2009
Other (please specify)

Services Interested in:

Services Interested in: CAHSEE Preparation Courses Career Academic Advisement High School Completion	GED Testing/ Preparation Job Readiness Workshop
Other (please specify):

How did you hear about the bridge to Success Program?

How did you hear about the bridge to Success Program? Class schedule/college catalog TV advertisement Phone outreach	Counselor/case manager Outreach letter Employer	College recruiter Friend/Family Internet
Other (please specify)

Please specify the following information

	MM		DD		YYYY
Today's Date:	Please specify the following information Today's Date: Month	/	Day	/	Year

Notes: (for office use only)

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