UT Youth Engagement Center RGV

UT Youth Engagement Center RGV

First Name*

Last Name*

Student ID#*

Date of Birth*

Gender*

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Ethnicity*

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Citizenship*

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Cell Phone #*

(Please use the following format: ###-###-####)

Email*

(Example, yahoo or gmail etc, not school issued)

Do you participate in any of the following programs? If not select None.*

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Mailing Street*

Mailing City*

Mailing State/Province*

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Mailing Zip/Postal Code*

First Generation*

Select

What is your lunch status at school?*

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School currently attending*

Select

Other School Name

Current Student Grade Level*

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Family Information

Parent/Guardian (1) Name*

Parent/Guardian (2) Name

Parent/Guardian Cell Phone #*

(Please use the following format: ###-###-####)

Parent/Guardian Email*

Parent/Guardian highest grade completed/attained

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Parent/Guardian address same as student

(Please check the box if the same, if not, please fill out address below)

Parent/Guardian Street

Parent/Guardian City

Parent/Guardian Zip Postal Code

Emergency Contact

Emergency Phone