Pre-Registration for Native Youth College and Career Institute

CIMCC's Native Youth College and Career Institute Pre-Registration Form

CIMCC in partnership with UC Berkeley's Joseph A. Myers Center and Native American Student Development is offering a program for Native American high school students that would like to access resources to assist them in obtaining higher education. The program will take place at UC Berkeley from June 24-27th, 2019.

Please note that completing this pre-registration form is only an indication to show that you are interested in participating in this institute. We will send out the complete application for this program once the details for the institute have been finalized.

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* 1. Name:

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* 2. Age

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* 3. Grade level

9th grade

10th grade

11th grade

12th grade

Transfer student

Other

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* 4. Email:

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* 5. Address:

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 6. Parent/Guardian Contact Information:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Pre-Registration for Native Youth College and Career Institute

CIMCC's Native Youth College and Career Institute Pre-Registration Form

Question Title

* 1. Name:

Question Title

* 2. Age

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* 3. Grade level

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* 4. Email:

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* 5. Address:

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* 6. Parent/Guardian Contact Information:

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* 7. Tribal Affiliation:

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* 8. Why do you want to attend this institute?

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* 1. Name:

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* 2. Age

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* 3. Grade level

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* 4. Email:

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* 5. Address:﻿

Question Title

* 6. Parent/Guardian Contact Information:

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* 7. Tribal Affiliation:

Question Title

* 8. Why do you want to attend this institute?

* 5. Address: