Student information as it appears in the school's record First Name * Middle Name Last Name * Nickname (If no nickname, just input your first name) Gender * - Select -MaleFemale Birth Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year199819992000200120022003200420052006 Contact Type * - Select -Cellular PhoneHome (Primary) Contact Number * Example: (888)888-8888 Home Address * Example: 6100 Wilshire Boulevard Apartment / Unit City * State * - Select -California Zip Code * Ethnicity * - Select -African-American/BlackHispanic/Latino(a)CaucasianNative American-IndianAsianPacific IslanderMulti-RacialOtherUnknown Current School * - Select -Crenshaw High SchoolGertz ResslerHamiltonNew DesignsNew Open World Academy Current Academic Grade * - Select -9101112 Expected High School Graduation Year * - Select -2018201920202021 Language Spoken At Home * Do you qualify for free or reduced lunch? - None -YesNo Parent/Guardian 1 Information Parent/Guardian First Name * Parent/Guardian Last Name * Relationship to Student * - Select -MotherFatherSisterBrotherStep-motherStep-fatherAuntUncleGrandmotherGrandfatherMother-in-lawFather-in-lawFoster motherFoster fatherCousin Parent/Gaurdian Marital Status * - Select -SingleMarriedSeparatedDivorcedWidowed Phone Type * - Select -Cellular PhoneHome (Primary)Work Contact Number * Example: (888)888-8888 Highest Level of Education COMPLETED by parent or guardian 1 * - Select -Elementary SchoolMiddle SchoolHigh School GraduateVocational or Trade CertificationAssociate DegreeBachelor's DegreeGraduate DegreeUnknown In case of an emergency, may we contact this person? * - Select -YesNo Parent/Guardian 2 Information Parent/Guardian First Name Parent/Guardian Last Name Relationship to Student - None -MotherFatherSisterBrotherStep-motherStep-fatherAuntUncleGrandmotherGrandfatherMother-in-lawFather-in-lawFoster motherFoster fatherCousin Parent/Guardian Marital Status - None -SingleMarriedSeparatedDivorcedWidowed Phone Type - None -Cellular PhoneHome (Primary)Work Contact Number Example: (888)888-8888 Highest Level of Education COMPLETED by parent or guardian 2 - None -Elementary SchoolMiddle SchoolHigh School GraduateVocational or Trade CertificationAssociate DegreeBachelor's DegreeGraduate DegreeUnknown In case of an emergency, may we contact this person? - None -YesNo Additional Information Name of your Small Learning Community or Magnet * - Select -Business, Entrepreneurship & Technology Magnet (BET)Business Interactive Technology Academy (BIT)Communications Arts Academy (CAA)Math Science Medical (MSM)Science, Technology, Engineering, Math & Medicine (STEMM)Visual & Performing Arts Magnet (VAPA)None Acknowledgement * - Select -YesNo I acknowledge by signing this form I am participating in the Fulfillment Fund's classroom based college access program. I have provided my information to the best of my knowledge and will have my parents sign the parent consent form in order for my enrollment in the program to be complete. I understand by not submitting my forms, I will not be able and or eligible to participate in experiential learning and workshop activities provided by the Fulfillment Fund. Today's Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018 Electronic Signature * CAPTCHAThis question is for testing whether you are a human visitor and to prevent automated spam submissions. Math question * 1 + 18 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.