* REQUIRED FIELD
Student Profile
* Date:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December
* Last Name:	* First Name:
* MI:	* Social Security Number:
* Gender	* Home Phone:
Male Female
* Street Address:	* City:
* State/Province/Country:	Date of Birth:
	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December
Ethnicity (check one):
Amerrican Indian/Alaskan Native Asian Native Hawaiian/Other Pacific Black/African American White Islander Hispanic/Latino Multiracial
* Disability Status:
Yes No - If yes, specify of disability and accommomdations needed
Parent Profile
Employment of Patron: (please check if applies to applicant)
Full-Time Part-Time
Unemployed Retired
check the box that indicates your family income level:
below - $14,597	$14,597-$19,629	$19,629-$24,661
$24,661 - $29,693	$29,693-$34,725	$34,725-$39,757
$39,757 - $44,789	$44,789-$49,821	$49,821-above
* Number of individuals in household:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
GOALS (check all that apply)
Test Preparation	Job Preparation	Work Related
School Related	Fun	Computer Skills
Personal	Tutoring	Community Service
Complete for student registration:
* PARENT OR GUARDIAN	* PHONE (if different):
* HOME SCHOOL:	* GRADE:
	1 2 3 4 5 6 7 8 9 10 11 12
* AGE:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 years

* TUTORING DAY:
Monday	Tuesday	Wednesday	Thursday