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PERSONAL INFORMATION
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NAME:
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Last Name
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First Name
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M.I.
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MAILING ADDRESS:
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PO Box or Street Address
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City
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State
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Zip Code
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Invalid Zip
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CONTACT PHONE NUMBER:
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###-###-####
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E-MAIL:
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Invalid Email
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PARENT/
GUARDIAN PHONE:
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###-###-####
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BIRTH DATE:
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*
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PRESENT AGE:
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Invalid Age
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U.S. CITIZEN:
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PREFERRED METHOD OF CONTACT:
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ETHNICITY:
Hispanic
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GENDER:
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RACE:
(check all that apply)
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SCHOOL INFORMATION:
Check the school you are CURRENTLY attending.
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Are you currently attending college or an applied technology college (ACT)?
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CURRENT GRADE IN SCHOOL:
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CURRENT GPA:
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Have you taken the ACT?
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PARENT/GUARDIAN INCOME
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Do you participate in Free or Reduced Lunch at school?
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Number of people in your family:
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Invalid Number
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Do either of your parents have a college degree (associate's or higher)?
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ARE YOU INTERESTED IN APPLYING FOR THE HCOP SUMMER PROGRAM?
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