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AAYHF Young Ladies Mentoring Program
Young Ladies Series
Date
*
-
Month
-
Day
Year
Date
Parent Name
*
First Name
Last Name
Number in Household
*
Income
*
Please Select
o - 20,000
20,001 - 50,000
50,001 - 80,000
80,001 - 100,000
100,001 +
Email
example@example.com
Phone Number
Please enter a valid phone number.
Zip Code
*
Age
*
Ethnicity
*
Please Select
Hispanic/Latino
Non-Hispanic/Latino
Race
*
Please Select
American Indian/Alaska Native
Asian
Black/African American
Hispanic
White
Native Hawaiian/Pacific Islander
Some Other Race
Two or More races
Gender
*
Please Select
Female
Male
Non-Binary
Best Contact
*
Please Select
Phone
Email
Youth Female Name
*
First Name
Last Name
Youth Age
*
Youth Grade
*
Youth School District
*
Please Select
AISD
Del Valle
Hutto
Manor
Pflugerville
Other
Youth Female#2 Name
First Name
Last Name
Youth #2 Age
Youth #2 Grade
Youth #2 School District
Please Select
AISD
Del Valle
Hutto
Manor
Pflugerville
Other
Do you want tutoring for your child?
Please Select
Yes
No
If yes, which subject
Please Select
Reading
Math
Science
English
Other
If Other, which subject?
Please Select
List Child(s) Name and Area of tutoring
Approved Media Release
*
Please Select
Yes
No
I certify that I receive the indicated income from the following source
*
Please Select
Full-time employment
Part-time employment
Unemployment
Social Security (SSI)
Other
I am self-declaring my identity as proof of identification at this time
*
Please Select
Yes
No
What are you expecting to gain out of this class?
Submit
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