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- Date of Birth*
- Gender:*
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- Are you a US Citizen?*
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- If not a US Citizen, are you a permanent resident?
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- If not, are you in the process of becoming a permanent resident?
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- Current Grade:*
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- Are you currently enrolled in another outreach program? (ex. AVID/EAOP/UB/UB Math & Science/GEARUP/etc.)*
- Ethnicity: Check all that apply*
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- Parent 1/Guardian Education:*
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- Parent 2/Guardian Education:
- Student Resides with:*
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- Does your child have a physical or learning disability:*
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- Please check the areas where you need assistance (check all that apply)*
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- Do you have other children in grades 6th - 12th?*
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- Date*
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- Date
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- Date*
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- Should be Empty: