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 *

(###)

###

####

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:

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Asexual

Bisexual

Gay

Heterosexual/Straight

Lesbian

Pansexual

Queer

Questioning

Prefer to self-describe:

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Race/Ethnicity:

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Black or African American

Hispanic or Latino/a/x

Asian

Native American or Indigenous

Middle Eastern or North African

White

Multiracial or Mixed Race

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Do you identify as a person with a disability?

Yes

No

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Housing Status

Own

Rent

Living with Family

Other

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