1. WILD Application - 2011 (January until October) Exit this survey Question Title * 1. YOUR CONTACT INFORMATION Full Name: * Nickname: Birthdate: Address: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Zip: * Phone Number: Cell Phone Number: Email Address: Question Title * 2. GENDER Female Male Other (please specify) Question Title * 3. GRADE LEVEL 9th Grade 10th Grade 11th Grade 12th Grade Other (please specify) Question Title * 4. What school do you currently attend? Question Title * 5. BACKGROUND INFORMATION Please choose one Do you have any learning disabilities? Yes No Do you have any learning disabilities? Please choose one menu Do you have any physical disabilities? Yes No Do you have any physical disabilities? Please choose one menu Are you limited in your ability to communicate in English? Yes No Are you limited in your ability to communicate in English? Please choose one menu Will you use the community service hours earned at WILD to fulfill graduation requirements? Yes No Will you use the community service hours earned at WILD to fulfill graduation requirements? Please choose one menu Are you currently employed? Yes No Are you currently employed? Please choose one menu Have you ever served on active duty in the U.S. Military? Yes No Have you ever served on active duty in the U.S. Military? Please choose one menu Do you currently receive tutoring help? Yes No Do you currently receive tutoring help? Please choose one menu Question Title * 6. TUTORING ASSISTANCE Writing Reading Math Science Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Writing Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Reading Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Math Please indicate if you'd like to receive tutoring assistance in any of the following subjects: Science Other (please specify) Question Title * 7. I am: Other an immigrant or refugee American-born If other (please specify) Question Title * 8. RACE ASIAN AFRICAN/AFRICAN AMERICAN/BLACK CAUCASIAN/WHITE HISPANIC/LATINO NATIVE AMERICAN/AMERICAN INDIAN Other (please specify) Question Title * 9. ETHNICITY Chinese Cambodian Filipino Mien Pacific Islander Hawaiian Vietnamese Korean Laotian Thai Other Other (please specify) Question Title * 10. If you are currently homeless, please provide the following information. How many times have you been homeless in the past three years? How long have you been homeless this last time (days, months, or years)? Question Title * 11. HOUSEHOLD SIZE INFORMATION: How many people live in your house? How many parents do you live with? What is your family's monthly income? Do you eat free lunch at school? Question Title * 12. Please list the names, ages, and relationships of everyone that lives with you, including yourself. 1) Name: Relationship to you: Are they under 18? 2) Name: Relationship to you: Are they under 18? 3) Name: Relationship to you: Are they under 18? 4) Name: Relationship to you: Are they under 18? 5) Name: Relationship to you: Are they under 18? 6) Name: Relationship to you: Are they under 18? Question Title * 13. PARENT/GUARDIAN INFORMATION Name: Phone: Name: Phone: Question Title * 14. How did you learn about WILD? (Check all that apply.) School teacher or counselor Sister or Brother WILD Staff Other organizations Friend Please specify other organization or friend (please specify) Next