Part 1 - Student Information

 

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

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

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

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

* 4. What is your: street address?

* 5. What is your: zip code?

* 6. Your gender is:

* 7. Are you Hispanic or Latino?

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

* 9. What high school do you attend?

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

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