1. WILD Application - 2011 (January until October)

 
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1. YOUR CONTACT INFORMATION
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2. GENDER
3. GRADE LEVEL
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4. What school do you currently attend?
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5. BACKGROUND INFORMATION
Please choose one
Do you have any learning disabilities?
Do you have any physical disabilities?
Are you limited in your ability to communicate in English?
Will you use the community service hours earned at WILD to fulfill graduation requirements?
Are you currently employed?
Have you ever served on active duty in the U.S. Military?
Do you currently receive tutoring help?
6. TUTORING ASSISTANCE
WritingReadingMathScience
Please indicate if you'd like to receive tutoring assistance in any of the following subjects:
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7. I am:
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8. RACE
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9. ETHNICITY
10. If you are currently homeless, please provide the following information.
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11. HOUSEHOLD SIZE INFORMATION:
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12. Please list the names, ages, and relationships of everyone that lives with you, including yourself.
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13. PARENT/GUARDIAN INFORMATION
14. How did you learn about WILD? (Check all that apply.)