Huckleberry Wellness Academy San Francisco Application (2018-2021)
Last Name: *
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First Name: *
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Address: *
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Gender *
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Race/Ethnicity: *
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Birthday (mm/dd/yy) *
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Cell Phone (xxx) xxx-xxx: *
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Home Phone (xxx) xxx-xxx: *
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Can you receive text messages? *
Email: *
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High School: *
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Grade: *
What is your current cumulative GPA? *
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Parent/Guardian Name: *
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Parent/Guardian Home/Cell Number: *
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Will your parent(s)/guardian(s) need translation in order to participate in Wellness Academy events? *
If you answered "yes" to the previous question, in what language does your parent/guardian need translation?
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Do you speak any other languages other than English? *
If you answered "yes" to the previous question, what language(s)?
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What actions are you currently taking that demonstrate your commitment to your education, and/or your interest in attending college? Please provide at least two specific examples. *
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What kind(s) of support will you need in order to do your best in high school and be fully prepared for the transition to college? *
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What was the highest level of education parent/guardian #1 achieved? *
What was the highest level of education parent/guardian #2 achieved? *
Do you qualify for free/reduced lunch? *
Please specify your total ANNUAL household income from 2017 (The number can be found by adding up the amount on all 2017 W2 forms, line 1): *
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How many people live in your household? *
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Please check the box(es) if you have siblings currently attending schools (check all that apply): *
Required
If you checked off any boxes in the previous question, please let us know how many siblings per category (For example: K-12: 4; attending college: 1)
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How did you find out about HYP Wellness Academy? (Please check one) *
Full name of the person who referred you: *
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