Girls Inc. of the Central Coast Smart Choices Program Application
Please complete the following information. Please note that there is a $360 fee for the Smart Choices Program. Click on the following link to submit your payment: https://www.paypal.com/donate/?token=tXGObYURjlmvSKamw7hgtNNKZZEotJipGw7XLJQldcURjXuNNtpOyp6iOxk2vQ6LYCDoPG&country.x=US&locale.x=US
Last Name: *
Your answer
First Name: *
Your answer
Middle Name:
Your answer
Mailing Address: *
Your answer
Apartment Number:
Your answer
City: *
Your answer
State: *
Zip Code: *
Your answer
Phone Number: *
Your answer
Birthdate: *
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DD
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YYYY
Mother's Full Name:
Your answer
Father's Full Name:
Your answer
Person to Contact in Case of Emergency: *
Your answer
Relationship to Applicant: *
Your answer
Emergency Contact Number: *
Your answer
Ethnic Group: *
(For statistical purposes only)
Race: *
(For statistical purposes only)
Annual Household Income: *
(For statistical purposes only)
Number of Family Members Living in Household: *
Your answer
Family Type: *
Primary Language Spoken at Home: *
Middle School Attending: *
Your answer
High School You Will Attend: *
Your answer
Do you plan to go to college?
If yes please answer the next question.
Are you involved in any other summer program? *
What program?
Your answer
Are you planning to attend summer school?
When do you start?
MM
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DD
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YYYY
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