Name *

First Name

Last Name

Preferred Name

First Name

Last Name

Phone *

(###)

###

####

Grade level *

Middle School (6th - 8th)

High School (9th - 12th)

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Second Emergency Contact

First Name

Last Name

Phone

(###)

###

####

Gender Indentity:

Select all that apply

Woman

Man

Non-binary

Transgender

Genderqueer/Gender non-conforming

Prefer to self-describe:

Prefer not to say

Sexual Orientation:

Select all that apply

Asexual

Bisexual

Gay

Heterosexual/Straight

Lesbian

Pansexual

Queer

Questioning

Prefer to self-describe:

Prefer not to say

Race/Ethnicity:

Select all that apply

Black or African American

Hispanic or Latino/a/x

Asian

Native American or Indigenous

Middle Eastern or North African

White

Multiracial or Mixed Race

Prefer to self-describe:

Prefer not to say

Do you identify as a person with a disability?

Yes

No

Prefer not to say

Housing Status

Own

Rent

Living with Family

Other

Prefer not to say