Exit this survey Alternative Teen Break 2014-2015 * 1. Please fill out the information below. Name: Address: Address 2: City: State: ZIP: Home Phone: Cell Phone: Email: First Name Last Name Address City State Zip Home Phone Cell Phone Email * 2. Please fill out the demographic information below. Gender: Date of Birth: Age: Grade: Graduation Year: School District: School Name: Gender Date of Birth Age Grade Graduation Year School District School Name * 3. Do you currently attend a Title I school and/or receive a free or reduced lunch? Yes No * 4. How did you find out about Alternative Teen Break (ATB)? Teacher Friend/Family Member Houston Zoo Facebook Houston Zoo Website Houston Zoo Email Next