* 1. Student's First Name:

* 2. Student's Last Name:

* 4. What is your graduation year?

* 5. Do you belong to any of the following Community Based Organizations?

* 6. Student's E-mail Address:

* 7. Confirm Student's E-mail Address:

* 8. Student's Primary Contact Number:

* 9. Parent/Guardian 1

* 10. Parent/Guardian 2 (if applicable)

* 11. Please specify if the student or parent/guardian needs special accommodations due to a disability.

* 13. Would you like to participate in a UC Riverside campus tour following the Achieve UC event?

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