Exit this survey YOUNG MEN'S EMPOWERMENT PROGRAM (YMEP) APPLICATION Question Title 1. Demographic Information Full Name: Age: Address: City: ZIP: Home Phone Number: Cell Phone Number E-Mail Address: Facebook Question Title 2. Gender: M F Transgender Question Title 3. Sexual Orientation: Straight Lesbian Gay Bisexual Queer Unsure Other (please specify) Question Title 4. Which Racial/Ethnic groups do you identify as (check all that apply) Cambodian Thai Vietnamese Laotian Hmong Chinese Korean Japanese Filipino Pacific Islander Black/African American White Latino Native American Other (please specify) Question Title 5. High School Attending: Polytechnic H.S. PAAL Wilson H.S. Other (please specify) Question Title 6. Grade Level: 9 10 11 12 Question Title 7. How did you hear about KGA? (check all that apply) Friend (type name in the text box 'Other' below) Sibling KGA Member/Staff Classroom Presentation Teacher/Counselor Attended an event Online(website, myspace, facebook) Other (please specify) Question Title 8. Why are you interested in joining KGA's Young Men's Empowerment Program? Question Title 9. What does brotherhood mean to you? And why is it important? Question Title 10. How would you contribute to building a powerful brotherhood with other young men and young women at KGA? Question Title 11. What is an important issue that young Khmer and/ or Southeast Asian men face in your community? Question Title 12. We want to know a little more about you. Anything else you want to share with us about yourself (ex: qualities,interests, goals, life struggles, etc)? Done!