SurveyMonkey Powered Online Survey

1. WILD Application - 2011 (January until October)

1. YOUR CONTACT INFORMATION

YOUR CONTACT INFORMATION Full Name:
Nickname:
Birthdate:
Address:
City/Town:
State:
Zip:
Phone Number:
Cell Phone Number:
Email Address:

2. GENDER

GENDER Female

Male

Other (please specify)

3. GRADE LEVEL

GRADE LEVEL 9th Grade

10th Grade

11th Grade

12th Grade

Other (please specify)

4. What school do you currently attend?

What school do you currently attend?

5. BACKGROUND INFORMATION

	Please choose one
Do you have any learning disabilities?	BACKGROUND INFORMATION Do you have any learning disabilities? Please choose one
Do you have any physical disabilities?	Do you have any physical disabilities? Please choose one
Are you limited in your ability to communicate in English?	Are you limited in your ability to communicate in English? Please choose one
Will you use the community service hours earned at WILD to fulfill graduation requirements?	Will you use the community service hours earned at WILD to fulfill graduation requirements? Please choose one
Are you currently employed?	Are you currently employed? Please choose one
Have you ever served on active duty in the U.S. Military?	Have you ever served on active duty in the U.S. Military? Please choose one
Do you currently receive tutoring help?	Do you currently receive tutoring help? Please choose one

6. TUTORING ASSISTANCE

	Writing	Reading	Math	Science
Please indicate if you'd like to receive tutoring assistance in any of the following subjects:	*TUTORING ASSISTANCE Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Writing	Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Reading	Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Math	Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Science

Other (please specify)

7. I am:

I am: Other

an immigrant or refugee

American-born

If other (please specify)

8. RACE

RACE ASIAN

AFRICAN/AFRICAN AMERICAN/BLACK

CAUCASIAN/WHITE

HISPANIC/LATINO

NATIVE AMERICAN/AMERICAN INDIAN

Other (please specify)

9. ETHNICITY

ETHNICITY Chinese Cambodian Filipino Mien Pacific Islander Hawaiian	Vietnamese Korean Laotian Thai Other
Other (please specify)

10. If you are currently homeless, please provide the following information.

If you are currently homeless, please provide the following information. How many times have you been homeless in the past three years?
How long have you been homeless this last time (days, months, or years)?

11. HOUSEHOLD SIZE INFORMATION:

HOUSEHOLD SIZE INFORMATION: How many people live in your house?
How many parents do you live with?
What is your family's monthly income?
Do you eat free lunch at school?

12. Please list the names, ages, and relationships of everyone that lives with you, including yourself.

Please list the names, ages, and relationships of everyone that lives with you, including yourself. 1) Name:
Relationship to you:
Are they under 18?
2) Name:
Relationship to you:
Are they under 18?
3) Name:
Relationship to you:
Are they under 18?
4) Name:
Relationship to you:
Are they under 18?
5) Name:
Relationship to you:
Are they under 18?
6) Name:
Relationship to you:
Are they under 18?

13. PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN INFORMATION Name:
Phone:
Name:
Phone:

14. How did you learn about WILD? (Check all that apply.)

How did you learn about WILD? (Check all that apply.) School teacher or counselor

Sister or Brother

WILD Staff

Other organizations

Friend

Please specify other organization or friend (please specify)