UT Youth Engagement Austin Entry Form

UT Youth Engagement Austin Entry Form

First Name*

Middle Name

Last Name*

Gender*

Female

Male

Other

Ethnicity*

Select or enter value

Citizenship

Select

Mobile Phone*

Home Phone

Email*

Facebook Name

Snapchat Name

Instagram Name

Twitter Handle

Mailing Street*

Mailing City*

Select or enter value

Mailing State*

Select or enter value

Mailing Zip Code*

DOB*

Parent/Guardian Name*

Parent/Guardian Email

P/G Highest Grade Completed

Select or enter value

Parent/Guardian address same as student

Please check if the same, if not, please fill out address below.

P/G Street

P/G City

Select or enter value

P/G Zip Code

Emergency Contact

Emergency Phone

Student Academic Information

Student Grade Level*

Select or enter value

High School*

Select or enter value

If you selected "other" high school, please list the name here

Student ID*

AVID

Currently Employed

First Generation

Free Reduced Lunch

Neighborhood Longhorns Program (NLP)

If NLP is checked, please add the elm/middle school name here.

The University of Texas at Austin and the school district have an agreement allowing UT Youth Engagement Center Austin access to student records i.e., report cards, school transcripts, test scores, rankings. The records will be used for evaluation purposes, scholarships, participation in events, etc. In agreement with the statement above, please check the box below.*

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