UT Outreach Houston Student Application

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* 1. Student Information

First Name:

Last Name:

Address:

City:

State:

Zip:

Student ID Number:

Email Address:

Cell Number:

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* 2. Which school do you attend?

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* 3. Date of birth?

	Month	Date	Year
.	. Month menu	. Date menu	. Year menu

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* 4. What is your gender?

Male

Female

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* 5. What is your race? (Check all that apply):

African-American

Asian-American

Caucasian

Hispanic

Native American

Other (please specify)

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* 6. What is your citizenship status?

US Citizen

Permanent Resident

Other (please specify)

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* 7. What is your lunch status?

Free

Reduced

Full Price

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* 8. What year is your graduating class?

2021

2020

2019

2018

2017

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* 9. Are you a part of any of the following programs? (Check all that apply):

Pre AP

Dual Credit

Magnet

Upward Bound

AVID

Chembridge

SPURS

NONE OF THE ABOVE

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* 10. Do you play sports at your school?

Yes

If yes, please specify what sports you play:

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* 11. Would you like to play sports at the collegiate level?

Yes

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* 12. Are you considering UT Austin as one of your college options?

Yes

Undecided at this time

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* 13. Who is your primary contact?

First Name

Last Name

Relationship to student:

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* 14. Do you live with your primary contact?

Yes

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* 15. Primary Contact Information

Employer: *

Occupation: *

Address: *

Address 2:

City: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 16. What is your primary contact's annual income?

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* 17. What is the highest grade completed by your primary contact?

Less than high school

High School Diploma

Technical/Trade Certificate

Associate Degree

Bachelor Degree

Master Degree

Professional Degree

Doctoral Degree

If less than high school diploma please enter grade:

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* 18. Who is your secondary contact?

First Name

Last Name

Relationship to student:

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* 19. Do you live with your secondary contact?

Yes

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* 20. Secondary Contact Information

Employer: *

Occupation: *

Address: *

Address 2:

City: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 21. What is the highest grade completed by your secondary contact?

Less than high school

High School Diploma

Technical/Trade Certificate

Associate Degree

Bachelor Degree

Master Degree

Professional Degree

Doctoral Degree

If less than high school diploma please enter grade:

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* 22. What is your secondary contact's annual income?

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* 23. Please select who you would like us to contact in case of emergency:

Primary Contact

Secondary Contact

Other (first name, last name and phone #)

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* 24. Family Data: Please indicate the total number of immediate family members (include yourself, your parents, your brothers and sisters).

Number of family members (including yourself):

Number of family members who live at home (including yourself):

Graduated from high school:

Attended college:

Completed a 2 year degree/certificate:

Earned a bachelor degree:

Earned a master degree:

Earned a professional degree:

Doctoral Degree: