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Girls Inc. of the Central Coast ECHO Leadership Program Application
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Last Name:
*
Your answer
First Name:
*
Your answer
Middle Name:
Your answer
Mailing Address:
*
Your answer
Apartment Number:
Your answer
City:
*
Your answer
State:
*
California
Other:
Zip Code:
*
Your answer
Participant E-mail Address:
*
Your answer
Home Phone Number:
Your answer
Cell Phone:
*
Your answer
School:
*
Your answer
Grade:
*
Your answer
Birthdate:
*
MM
/
DD
/
YYYY
Age:
*
Your answer
Ethnic Group:
*
(For statistical purposes only)
Hispanic
Not Hispanic
Race:
*
(For statistical purposes only)
White
African American
Asian/Pacific Islander
American Indian
Multiracial
Other:
Annual Household Income:
*
(For statistical purposes only)
Under $10,000
$10,001-$15,000
$15,001-$20,000
$20,001-$25,000
$25,001-$30,000
$30,001-$50,000
Over $50,001
Number of Family Members Living in Household:
*
Your answer
Family Type:
*
Two Parents
Mother Only
Father Only
Relatives(not parents)
One Parent at a time(Joint Custody)
Foster Parents
Other:
Primary Language Spoken at Home:
*
English Only
Spanish Only
English & Spanish
Other:
Mother's Full Name:
Your answer
Mother's Phone Number:
Your answer
Father's Full Name:
Your answer
Father's Phone Number:
Your answer
Person to Contact in Case of Emergency:
*
Your answer
Emergency Contact Number:
*
Your answer
Relationship to Applicant:
*
Your answer
Do you work after school?
*
(If yes, see page 2)
Yes
No
What other clubs, sports or community groups are you involved in?
Your answer
Hobbies or Interests:
Your answer
Do you plan to go to college?
If yes please answer the next question.
Yes
No
Undecided
Clear selection
Major:
(If undecided leave blank.)
Your answer
Schools of Interest:
(If not sure leave blank.)
Your answer
How did you hear about this program?
Your answer
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