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Applicant Portion

This segment is for the youth who is applying, below there will be some questions the parent/guardian must complete to submit the application.

Eureka! Program
Eureka! is a five year teen achievement program at Girls Inc. of Alameda County.

Please note this is confidential information that will not be shared externally.

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* 1. Applicant's Full Name

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* 2. Applicant's Date of Birth

Date

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* 3. Applicant's Primary Home Address

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* 4. Applicant's Cell Phone (if applicable)

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* 5. Applicant's Email Address

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* 6. Please select your preferred method of contact

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* 7. What middle school do you currently attend?

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* 8. What grade are you in?

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* 9. What Race/Ethnicity do you identify as? Please check all that apply.*
*(optional, for statistical purposes only)

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* 10. How did you learn about Eureka? Please list name(s) if applicable.

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* 11. Are you involved or have you been involved with any Girls Inc. programs?
(Select all that apply)

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* 12. Do you have family members who have been part of the Girls Inc. Program?
(Please list there name and the program they were in)

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* 13. Are you involved in any extracurricular activities in or out of school, including sports teams? If applicable, please list activities:

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* 14. Why do you want to be part of the Eureka! Program?
(Please answer in two to three sentences)

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