Pipeline Student Application

Pipeline

Student Application
Name*

First NameLast Name
School Attending*
Grade*
Social Security Number*
No spaces, only numbers.
Birthdate*

MonthDayYear
School ID #*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Student Cell Phone Number*

Area CodePhone Number
Student Email*
example@example.com
Gender*
Ethnicity*
Who do you live with? *

MotherFatherBoth
What language is spoken at home? *

EnglishSpanish
Are you a US Citizen?*

YesNo
Parent/Guardian Information
Guardian's Name*

First NameLast Name
Relation to child*

MotherFatherGrandparentGuardian
Phone Number*

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Guardian’s Name

First NameLast Name
Relation to child

MotherFatherGrandparentGuardian
Phone Number

Area CodePhone Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Are you, or have you ever been, a member of the Boys & Girls Club of the Tennessee Valley? *

YesNo
If yes, at which Club were you a member?
I wish to be a member of the Pipeline Program of Boys & Girls Clubs of the Tennessee Valley. Please contact my parent(s) or guardian(s) so that they can complete the application process.
Student's Signature

Clear
Date*
Individual Needs Assessment
What are your plans after high school? *

Attend a 4-year college / universityJoin the militaryAttend a community collegeAttend a trade / technical schoolWork full timeI am not sure of my plans yet
What subjects do you struggle with?*

MathScienceEnglishHistoryForeign Language
Why do you want to go to college?*
What careers related to healthcare interest you? *
Do you have a computer with internet access at home? *

YesNo
In which of these areas listed do you need assistance? (please check all that apply) *

Academic assistance and AdvisementCollege Awareness and Admissions AssistanceFinancial Aid Information and Application AssistanceCareer Awareness and ExplorationEconomic and Financial Literacy
Should be Empty:

Pipeline

Parent/Guardian Information

Individual Needs Assessment