Part 1 - Student Information

 

This information will be used as contact information for Follow Up reporting.

Your name is: (last, first)

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* 1. Your name is: (last, first)

Your home phone number is: (area code-prefix-number)

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* 2. Your home phone number is: (area code-prefix-number)

Your cell phone number is: (area code-prefix-number)

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* 3. Your cell phone number is: (area code-prefix-number)

What is your: street address?

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* 4. What is your: street address?

What is your: zip code?

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* 5. What is your: zip code?

Your gender is:

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* 6. Your gender is:

Are you Hispanic or Latino?

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* 7. Are you Hispanic or Latino?

What is your race? (Please select all that apply.)

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* 8. What is your race? (Please select all that apply.)

What high school do you attend?

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* 9. What high school do you attend?

What month will you graduate (or have you graduated) high school?

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* 10. What month will you graduate (or have you graduated) high school?

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