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Student Information

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* 1. Student Information:

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* 2. Gender:

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

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

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

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

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* 7. Are you a United States Citizen?

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

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

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* 10. Residential Address:

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* 11. Email Address:

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

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

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

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

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