UT Youth Engagement Center

UT Youth Engagement Center - SA

Student Information

First Name*

Middle Name

(leave blank if you do not have one)

Last Name*

Date of Birth*

Gender*

Select or enter value

Ethnicity*

Select or enter value

Student Cell Number*

Phone

Student Email*

(school issued)

Personal Student Email

(icloud, gmail, yahoo, etc)

Student Home Address*

City*

State*

Select or enter value

Zip Code*

Student ID*

Grade Level*

Select

High School Class Of*

Select

Campus*

Select

Lunch Status*

Select

Are you a First Generation Student?”*

A student whose parent(s)/legal guardian(s) have not completed a bachelor's degree

Select or enter value

Program Participation*

Are you involved in any of the listed programs below? Select all that apply

Select or enter value

Other Participation

Please only fill out if you selected "other" in the previous question

Family Information

Parent/Guardian (1) First & Last Name*

Parent/Guardian (1) Cell Phone #*

Phone

Parent/Guardian (1) Email*

Check box if address is the same as student, if not fill out below

Street

City

State

Select or enter value

Zip Code

Highest grade level Parent/Guardian (1) completed*

Select or enter value

Parent/Guardian (2) First & Last Name

Parent/Guardian (2) Cell Phone #

Phone

Parent/Guardian (2) Email

Check box if address is the same as student, if not fill out below

Street

City

State

Select or enter value

Zip Code

Highest grade level Parent/Guardian (2) completed

Select or enter value

Parent/Guardian Consent:

By checking this box, the parent/guardian authorizes the school district to release records to UTYEC staff

By checking this box, an email will be sent to the parent/guardian from DocuSign to review and sign this student application

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