EXIT THIS SURVEY Exit this survey YOUNG MEN'S EMPOWERMENT PROGRAM (YMEP) APPLICATION 1. Demographic Information Full Name: Age: Address: City: ZIP: Home Phone Number: Cell Phone Number E-Mail Address: Facebook 2. Gender: M F Transgender 3. Sexual Orientation: Straight Lesbian Gay Bisexual Queer Unsure Other (please specify) 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) 5. High School Attending: Polytechnic H.S. PAAL Wilson H.S. Other (please specify) 6. Grade Level: 9 10 11 12 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) 8. Why are you interested in joining KGA's Young Men's Empowerment Program? 9. What does brotherhood mean to you? And why is it important? 10. How would you contribute to building a powerful brotherhood with other young men and young women at KGA? 11. What is an important issue that young Khmer and/ or Southeast Asian men face in your community? 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!