American Indian Graduate Center College Readiness Program Registration Survey

1.What is your Name?

(Required.)

First Name

Last Name

2.What is your gender?

Female

Male

Other (please specify)

3.What is your address - State?(Required.)

4.What is your address - City & Zip Code?(Required.)

City:

Zip Code:

5.What is your email address?(Required.)

6.What is your phone number with area code (xxx)xxx-xxxx?(Required.)

7.What is the name of your High School?(Required.)

8.What is your High School's State?(Required.)

9.What is your Tribal affiliation (enter "n/a" if not applicable)?(Required.)

10.Which best describes you?(Required.)

11.How did you hear about our College Readiness Program?(Required.)

12.Will your parent(s) or guardian(s) be attending?(Required.)

Yes

No

13.What is your parent(s) or guardian(s) name?

First Name

Last Name

First Name

Last Name

14.What is your parent(s) or guardian(s) email address?

15.What is your parent(s) or guardian(s) phone number?

16.Are you under 18?(Required.)

Yes

No

17.The American Indian Graduate Center has my permission to use my or my child's photograph publicly to promote the organization. I understand that the images may be used in print publications, online publications, presentations, websites and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. By checking this box and typing my name below, I am electronically signing this Photo Release.(Required.)

I agree

I don't agree

Please type your name for electronic photo release