Student Information

* 1. Student Information:

* 2. Gender:

* 3. Race (U.S. Census Bureau); select all that apply:
Students identifying as Hispanic or Latino may be of any race.

* 4. Ethnicity (U.S. Census Bureau):

* 5. Do you have a disability? (If "Yes", answer next question. If "No", move to question 7)

* 6. What type of disability do you have? (You may fill out multiple boxes)

* 7. Are you a United States Citizen?

* 8. Have you served in the United States Military Service?

* 9. Date of Birth (MM/DD/YYYY)

* 10. Residential Address:

* 11. Email Address:

* 12. Phone Number (XXX-XXX-XXXX):

* 13. Congressional District for Address (Ex. "CA-49")
Visit http://house.gov to find district

* 14. Will you or your siblings be the first in your family to graduate from
college?

* 15. Have you ever qualified for subsidized school lunch?

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