Edúcate Registration for Current Cuesta Students Question Title * 1. Contact InformationSTUDENT NAME Question Title * 2. Cuesta College ID Number: Question Title * 3. MAILING ADDRESS Question Title * 4. Address 2: Question Title * 5. CITY/TOWN: Question Title * 6. STATE: CALIFORNIA Other (please specify) Question Title * 7. ZIP: Question Title * 8. EMAIL ADDRESS: Question Title * 9. CELL PHONE FOR UPDATES: Question Title * 10. RE-ENTER EMAIL ADDRESS: Question Title * 11. LISTING FOR NAME TAG (FIRST NAME OR NICKNAME): Question Title * 12. 4. Have you attended the Edúcate-Sí Se Puede in the past? Yes No Question Title * 13. 5. How did you find out about Edúcate- Sí Se Puede Conference? Counselor or Teacher Friend or Family Newspaper, TV, Radio or Website Flyer Other Question Title * 14. What size t-shirt do you want? X-Small Small Medium Large X-Large XX-Large Question Title * 15. 7. Do you need a vegetarian lunch? Yes No Question Title * 16. 8. Do you have any special needs or accommodations we should know about? Question Title * 17. How many semesters have you attended Cuesta College? One Semester Two Semesters Three Semesters Four Semesters Five or More Semesters Question Title * 18. What is your birth date (MM/DD/YYYY)? Question Title * 19. Are you male or female? Male Female No Response Question Title * 20. Ethnicity/Race (Select ALL that apply): Mexican, Mexican-America, Chicano Central American South American Hispanic: Other Asian: Indian Asian: Japanese Asian: Chinese Asian: Korean Asian: Laotian Asian: Cambodian Asian: Vietnamese Filipino Asian: Other Black or African American Native American/Alaskan Native Pacific Islander: Guamanian Pacific Islander: Samoan Pacific Islander: Other White Question Title * 21. Were you born in the United States? Yes No Question Title * 22. If you answered no to the above question, what country were you born in? Question Title * 23. Are you interested in learning more about what to do if you are an AB 540 student/ undocumented student/ a Dreamer? Yes No Question Title * 24. What is your educational goal at Cuesta College (select ALL that apply)? earn Associate Degree and transfer to a 4-year university earn Associate Degree and enter the workforce earn a technical certificate become a Registered Nurse to learn for self-improvement Other (please specify) Question Title * 25. What is your biggest challenge in meeting your educational goals (select ALL that apply)? Academics (school work, study skills, ability to understand and complete assignements) Peer Issues (personal relationships, drug/alcohol abuse, gangs) My immigration status Family issues/beliefs Language barriers Financial (being able to afford college) Other (please specify) By submitting this registration form, I authorize Cuesta College to use photos taken of me during the event for media releases and future advertisements related to this event. Done